Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dronabinol cap 2.5mg for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this medication falls under Part D coverage.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dronabinol cap 2.5mg for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 18, 2021.

You asked the Plan to pay for the office visit. You say that you were told that you could see this provider at the
out-of-network coverage percentage. The Plan denied your request. The Plan says the services received are not
a covered benefit.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office visit provided on January 18, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (HCPCS S1015, S8301, CPT 99199) provided to the enrollee on December 9, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the claim should be resubmitted.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 99199 is not supported in the medical record. Specifically, this code should not be billed by anesthesia practitioner. 

We find that HCPCS S1015 and S8301 are not supported in the medical records. Specifically, these codes have a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the codes are not valid for Medicare purposes. 

Based on this information, we decided that Medicare rules for coverage of the services have not been met.

Therefore, we decided that the Plan does not have to pay for home health services (HCPCS S1015, S8301, CPT 99199) provided to the enrollee on December 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on February 3, 2021.

You asked the Plan to pay for the laboratory services. You say that the services were medically reasonable and necessary as ordered by the patients treating nephrologist. You say that the provider has an exclusive agreement with the dialysis facility the patient received treatment and payment should be issued. The Plan denied your request. The Plan says prior authorization was required but not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on February 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says you are not testing your blood glucose four times or more per day.

The Plan must follow Medicare rules. Medicare rules say that a continuous glucose monitor is covered if the beneficiary is testing blood glucose levels four or more times per day.

We looked at the file and Medicare rules. The file shows that you are not testing your blood glucose levels four or more times per day. This is a requirement for coverage of the requested monitor. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided to the enrollee on October 14,
2020 and billed under code 88307.

You asked the Plan to pay for pathology services provided to the enrollee. You say that this claim should be
paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. The Qualified Independent Contractor (QIC) overturned the Plans denial. The Plan requested are reopen and stated that the QIC did not apply the correct billing
criteria. The Plan states this claim denied because the service was billed with an inappropriate diagnosis code.
The Plan states the claim image that shows the provider billed diagnosis code K31.7 for Polyp of stomach and
duodenum. The Plan states the diagnosis code does not support the level of surgical pathology described by the
code definition of CPT Code 88307. The Plan states the provider needed to bill CPT Code 88305 for "Level IV
Surgical pathology: gross and microscopic examination, abortion, spontaneous/missed Artery, biopsy, bone
marrow, biopsy, bone exostosis Brain/meninges." This is a more appropriate to bill with diagnosis code K31.7.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case the claim did
not deny for medical necessity. The claim denied because the appropriate code was not billed. Medicare billing
and coding criteria were not met. Therefore, we decided that the Plan does not have to pay for pathology
services provided to the enrollee on October 14, 2020 and billed under code 88307.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says the admission to an IRF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require an intensive rehabilitation therapy program. 

Medically necessary services can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found he patient is medically stable with no evidence of need for supervision by a physician or in need of acute rehab nursing care. the enrollee may benefit from further physical therapy, but does not require an intensive therapy program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Specifically, medically necessary services can be provided at a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan denied your request. The Plan says the IRF admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the provided documentation does not indicate that the enrollee requires the intensity of services provided at an IRF. The reviewer found that the enrollee is not shown to require 15 hours per week of rehabilitative services and regular physician evaluation.

Therefore, the reviewer found that the requested IRF care is not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Specifically, the enrollee does not require the intensity of services provided at an IRF. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 21, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for imaging services provided to the enrollee billed under Claim A.

You asked the Plan to pay for imaging services billed to the enrollee. You say that this claim should be paid.
The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the
Plans denial. The Plan requested a reopen and stated that Claim A denied because the Plan previously paid for this
service to another provider of the same group. This service was not provided twice on the same day. The NPI website
shows that both providers practice as Radiology Specialists. The claims show both providers are in the same physician
group. Claim A needed to be submitted with modifier 59; which is used to distinguish a different session or patient
encounter, or a different service.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one
service is provided on the same day to the same patient by the same physician or more than one physician in
the same specialty in the same group, only one service may be reported unless the services are for unrelated
problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group
relationship between the two providers and the omission of the modifier required to identify this as a separate
and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have
to pay for imaging services provided to the enrollee and billed under Claim A.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Imfinzi solution 500mg/10ml for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of Imfinzi in the setting of stage IV non-small-cell lung cancer have not been demonstrated in the peer-reviewed literature.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found that in this case, the record indicates that the enrollee has non small cell lung cancer, poorly differentiated carcinoma (dx 11/2020 as Stage IIIA, T3N1M0), EGFR -, ALK -, PDL1 -, BRAF -, KRAS G12S mut, MSI-S; no actionable mutations, that is metastatic to the brain. The enrollee has stage IV lung cancer. No published literature from Medicare approved cancer journal compendia was submitted. The elements of the coverage criteria are not satisfied. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Imfinzi solution 500mg/10ml for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for care in an LTACH. The Plan denied your request. The Plan says the guidelines for coverage of LTACH services have not been met. The Plan says that the enrollee could be cared for at a lower level of care.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted with sepsis and hypercapnic respiratory failure. The enrollee continues to be critically ill. The enrollee continues to receive acute critical care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve leuprolide acetate (Lupron).

You asked the Plan to pre-approve Lupron. The Plan denied your request. The Plan says that the clinical information does not support the use of the drug.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Lupron. Our physician reviewer found that the enrollee has prostate cancer. The requested use of Lupron is supported by compendia as palliative therapy, with response. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Lupron have been met. Therefore, we decided that the Plan has to pre-approve leuprolide acetate (Lupron).

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcutaneous electrical nerve stimulation (TENS) device.

You asked the Plan to pre-approve the TENS device. You say that you just had a complete shoulder replacement on the left side, and you need the device for relief of pain. The Plan denied your request. The Plan says medical necessity has not been met because the records do not show that the pain has lasted for at least 3 months prior to the TENS unit being ordered.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the TENS device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the request being made around 4/28/21 which was less than 3 months after the surgery and less than 3 months of pain, and as the surgery was not recent for the pain to be considered post-operative, the criteria is not met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the TENS device have not been met. Therefore, we decided that the Plan does not have to pre-approve transcutaneous electrical nerve stimulation (TENS) device.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says Part B step therapy criteria are not met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee has osteoarthritis. The record indicates that the requested drug is a new start. The enrollee has not tried and failed the plan's preferred step one agents. The prescriber has not indicated that the plan's preferred step one agents are not appropriate for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the wireless capsule endoscopy (91110).

You asked the Plan to pre-approve the wireless capsule endoscopy. You say that please consider approval of the capsule endoscopy for this enrollee to ensure the highest standard of care, given his history. The Plan denied your request. The Plan says the documentation does not support that the requested service is medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the wireless capsule endoscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the record indicates that the enrollee has known gastric antral vascular ectasia, last being treated with ablation in January 2021. No EGD has been repeated. Colonoscopy revealed internal hemorrhoids. The enrollee has iron deficiency anemia via lab values and also has chronic kidney disease stage 3b. A gastrointestinal source of bleeding has been identified. The elements of the coverage rule are not satisfied, and the requested service is not recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the wireless capsule endoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve the wireless capsule endoscopy (91110).