Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the office visit. You say that you are trying to get an appointment for a final follow-up visit with your doctor. The Plan denied your request. The Plan says the provider is out-of-network.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office visit to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Caris MI Tumor Seek testing on November 2, 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 not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is covered when specific criteria are met. 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has recurrent glioblastoma in the left temporal lobe. A hereditary cancer syndrome was suspected. She does not have stage III or IV cancer. The criteria for coverage are not met, and Medicare does not cover testing which is not reasonably expected to impact the management and outcome of the enrollee. The records do not support that the Caris MI Tumor Seek panel would affect the enrollee's medical management or outcome. The testing was therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the Caris MI Tumor Seek testing on November 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that you need long term hospital care. The Plan denied your request. The Plan says you do not require a transfer to the LTACH.
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 you do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. Our reviewer found that there are no services available at the LTACH that you require that are not available at the health care setting being offered by the Plan. Our physician reviewer also found that the requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and able to be furnished safely and effectively only on an inpatient basis.
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 27, 2020.

You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg.

We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met.

Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed.

Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture services to be provided by an out-of-network provider.

You asked the Plan to pre-approve the out-of-network acupuncture services. You say that the services are medically necessary. The Plan denied your request. The Plan says the requested provider is out-of-network and does not participate in the Medicare program. The services are not emergent and not pre-approved.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve acupuncture services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia supplies (82948, A4253, A4649, A4550, 99072, A9901, A9999, S1015, S3801).

You asked the Plan to pay for anesthesia supplies. You say that you needed anesthesia for your procedure. The Plan denied your request. The Plan says these items cannot be paid as billed.

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 codes 82948, A4253, A4649, A4550, 99072, A9901, A9999, S1015, and S3801 cannot be paid as billed. Specifically, codes A4253 and A4649 have a status code of P and codes A4550 and 99072 have a status code of B, indicating that payment for these items cannot be made separately from other services. Codes 82948, A9901 and A9999 have a status code of X, indicating that these items are statutory exclusions. Codes S1015 and S3801 have a status code of I, indicating that these codes are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of anesthesia supplies have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia supplies (82948, A4253, A4649, A4550, 99072, A9901, A9999, S1015, S3801).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on
January 22, 2021.

You asked the Plan to pay for the office visit. You say that you weren't aware you had to see someone in-network.
The Plan denied your request. The Plan says this provider is not a network provider with the Plan and
the services were not approved in advance.

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 had network providers
available who could have provided the items/services at issue in this appeal. 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 the office visit provided by an out-of-network
provider on January 22, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Botox.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that Botox is covered when specific criteria are met. 

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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has overactive bladder. He failed Vesicare and Oxybutynin. Botox is FDA-approved for overactive bladder in the setting of having been intolerant to or refractory to anticholinergic medications, such as in this enrollee's clinical situation described in the records. The criteria for coverage are met and Botox is reasonable and medically 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 these services have been met. Therefore, we decided that the Plan has to pre-approve Botox.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gemcitabine Hydrochloride (J9201) and Paclitaxel (J9264).

You asked the Plan to pre-approve Gemcitabine Hydrochloride and Paclitaxel. You say that the enrollee had a prior excellent response to these drugs. The Plan denied your request. The Plan says these drugs are not medically necessary.

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 Gemcitabine Hydrochloride and Paclitaxel. Our reviewer says that Gemcitabine Hydrochloride (J9201) and Paclitaxel (J9264) are not medically reasonable and necessary for the enrollee. Our physician reviewer found the review has determined that the documentation indicates worsening of the enrollee's condition with use of Gemcitabine plus Abraxane. It is not supported to repeat treatment with these medicines if the condition worsened while taking these medicines, which in this case the enrollee's condition worsened. Abraxane is contraindicated and is not to be rechallenged in enrollee's who experience a severe hypersensitivity reaction to Abraxane with this drug. In this case, the requested use of Gemcitabine Hydrochloride (J9201) and Paclitaxel (J9264) is not FDA-approved for the enrollee's diagnosis. Their use in this case is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services approved medical journal. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gemcitabine Hydrochloride and Paclitaxel have not been met. Therefore, we decided that the Plan does not have to pre-approve Gemcitabine Hydrochloride (J9201) and Paclitaxel (J9264).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiac genetic screening panel testing provided on August 27, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular disease.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The tests at issue in this appeal, genetic testing, were requested for screening purposes. Medicare does not cover these tests for screening purposes. Therefore, we decided that the Plan does not have to pay for cardiac genetic screening panel testing provided on August 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural steroid injection.

You asked the Plan to pre-approve the epidural steroid injection. You say that you would like reconsideration
because this service is medically necessary. The Plan denied your request. The Plan says this service cannot be
supported without a treatment plan showing that the required limits will not be exceeded.

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 epidural steroid injection. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found standard of care requires image guidance in order to perform an epidural.
Further, the duration and degree of pain relief from prior injections should be documented. 

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 epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya for the enrollee.

You asked the Plan to pre-approve Ilumya. You say that this is medically necessary. The Plan denied your
request. The Plan says that the member has not tried and failed the preferred step therapy drugs.

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 Ilumya. Our reviewer says that Ilumya is not medically reasonable and necessary for the enrollee. The enrollee has moderate to severe plaque psoriasis. The requested drug is a new start. The enrollee has not trialed the plan's preferred step one agents. You have not indicated that the enrollee cannot use or would have an adverse result from the Plan's preferred step one agents. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Ilumya. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve treatment with Carboplatin (J9045).

You asked the Plan to pre-approve Carboplatin. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says that the requested drug is not supported when given with radiation.

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 Carboplatin. Our physician reviewer found that the request is for Carboplatin with radiotherapy for bladder cancer. Carboplatin is a radiosensitizer and can be substituted for Cisplatin. Our reviewer says that the requested treatment is medically reasonable and necessary per the Medicare-approved compendia.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Carboplatin have been met. Therefore, we decided that the Plan has to pre-approve treatment with Carboplatin (J9045).

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.