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

We decided that the Plan does not have to pre-approve human growth hormone injections.

You asked the Plan to pre-approve human growth hormone injections. You say that this request is medically necessary. The Plan denied your request. The Plan says the requested procedure has not been shown to provide a benefit in patients with advanced arthritis of the knee.

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 human growth hormone injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/ investigational procedure. The abstract presented has not been published as a peer reviewed article. The request 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 human growth hormone injections have not been met. Therefore, we decided that the Plan does not have to pre-approve human growth hormone injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CPAP device.
You asked the Plan to pre-approve a CPAP device. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria.
The Plan must follow Medicare rules. Medicare rules say that adherence to therapy for continued coverage of a CPAP device is defined as 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. We looked at the file and Medicare rules. In this case, there was insufficient documentation provided to verify if the enrollee meets Medicare criteria for the requested CPAP device. Therefore, we decided that the Plan does not have to pre-approve a CPAP device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable continuous positive airway pressure (CPAP) device.

You asked the Plan to pre-approve a portable CPAP device. You say that you believe that this equipment is medically necessary. The Plan denied your request. The Plan says Medicare does not cover duplicate durable medical equipment and does not cover items designed to be used outside the home.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The rules also state that if DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. In addition, this item serves the same purpose as equipment you already have. Therefore, we decided that the Plan does not have to pre-approve a portable continuous positive airway pressure (CPAP) device.
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 you disagree with the denial. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found you were admitted to the hospital for pneumonia and a hip fracture. You are now medically stable with no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. You may benefit from further therapy but do not require an intensive therapy program in an IRF. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on November 27, 2020.
You asked the Plan to waive the copayment for the laboratory work. You say that you should not be responsible for the $10 copayment because the blood work was a part of your routine annual physical exam. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for Medicare-covered laboratory tests. This copayment does not apply to blood draws or INR testing (anti-coagulant testing). You will only pay one copayment per day even if multiple laboratory tests are performed. You have been asked to pay a $10 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the laboratory work is considered a separate service.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the laboratory work provided on November 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a virtual colonoscopy for the enrollee.
You asked the Plan to pre-approve a virtual colonoscopy for the enrollee. You say that the enrollee had an
incomplete colonoscopy in 2019 and is due for a screening. The Plan denied your request. The Plan says
Medicare coverage criteria are not met.
The Plan must follow Medicare rules. Medicare rules say a virtual colonoscopy is covered diagnostically for
certain physical situations but is not covered as a screening. This virtual colonoscopy was ordered as a
screening. The last incomplete colonoscopy was 2019. Medicare coverage criteria are not met. Therefore, we
decided that the Plan does not have to pre-approve a virtual colonoscopy for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Icosapent capsules.
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 self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Icosapent capsules.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for established patient domiciliary, rest home visit (99336) provided on November 3, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary, rest home visit. You say that the doctor is a hospitalist physician and depends upon the hospital staff to verify eligibility and to obtain proper authorization from the insurance company. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 established patient domiciliary, rest home visit (99336) provided on November 3, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dialysis services (90935, 90999) to be provided by an OON provider.
You asked the Plan to pre-approve OON dialysis services. You say that this is medically necessary. The Plan denied your request. The Plan says this is available in-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 services at issue in this appeal. The records do not show that the enrollee is outside of the Plan's service area. 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 dialysis services (90935, 90999) to be provided by an OON provider.
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 this is medically necessary. The Plan denied your request. The Plan says you can be treated at a lower level of care.
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 you do not require treatment by multiple therapies and an intensive rehabilitation therapy program. While you do require physical and occupational therapy, there is no documented need for an intensive rehabilitation 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orencia (J0129).

You asked the Plan to pre-approve Orencia. You say that the drug is medically necessary. The Plan denied your request. The Plan says there is no documentation showing that the patient tried and failed a conventional therapy and the Plan's preferred medications.

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 Orencia. Our reviewer says that the drug is not medically necessary. Our physician reviewer found the medical records do not show that the requested DME (Orencia) is medically necessary instead of the Plan's formulary products (Inflectra (infliximab-dyyb) or Renflexis (infliximab-abda). 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orencia have not been met. Therefore, we decided that the Plan does not have to pre-approve Orencia (J0129).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional LogistiCare mileage.
You asked the Plan to pre-approve additional LogistiCare mileage. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you are covered for up to 24 one-way trips per calendar year, not to exceed 50 miles per one-way trip.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way transportation trips per year, not to exceed 50 miles per one-way trip.
We looked at your request, the records in the case file, and the rules. The file shows that you are asking for an additional 5 miles per one-way trip. Your contract clearly shows that you are only covered for up to 50 miles per one-way trip. Therefore, we decided that the Plan does not have to pre-approve additional LogistiCare mileage.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care from August 4, 2021, onward.

You asked the Plan to pre-approve inpatient mental health care. You say that the enrollee is not safe for discharge. The Plan denied your request. The Plan says a lower level of care is more appropriate.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

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 inpatient mental health care. Our reviewer says that the requested inpatient care is not medically necessary. Our physician reviewer found based on the records provided, it is not expected this enrollee would improve in a reasonable period of time beyond the Plan-approved dates as he was not showing any dangerousness to self or others, auditory or visual hallucinations, or aggressive behaviors. He was not showing any acute threats of safety. The patient was cooperative and compliant with medication. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower 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 inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care from August 4, 2021, onward.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve use of Tyvaso (treprostinil inhalation solution).
You asked the Plan to pre-approve Tyvaso. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the enrollee does not meet the Medicare criteria for the requested use of Tyvaso.
The Plan follows Medicare rules. Medicare rules state that Tyvaso may be covered under certain clinical conditions. 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 Tyvaso. Our reviewer says that the enrollee meets the Medicare criteria for the requested use of Tyvaso. Our physician reviewer found the enrollee has severe group 3 pulmonary arterial hypertension secondary to interstitial lung disease. A clinical study has shown benefit for patients with this type of pulmonary arterial hypertension, and the Food & Drug Administration (FDA) has recently approved this indication for Tyvaso. The enrollee is on the appropriate treatment for her condition. There are no good alternative treatments for this condition. Tyvaso is considered medically necessary 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 Tyvaso have been met. Therefore, we decided that the Plan has to pre-approve use of Tyvaso (treprostinil inhalation solution).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on April 9, 2021.
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed with an incorrect place of service.
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 CPT Code Manual definition of code 71045 is radiologic examination, chest; single view. We find that CPT code 71045 is not supported in the medical record. Specifically, this code was billed with place of service 22 (outpatient); however, the documentation supports that the enrollee was inpatient during this date of service. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 provided on April 9, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 11, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on September 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiologic examination, chest (71045) transportation of portable X-ray equipment and personnel to home or nursing home (R0070) set-up portable x-ray equipment (Q0092) provided on January 13, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the portable x-ray services. You say that your services are treated as an emergency service in the nursing home and home health settings as these facilities are required by CMS to treat potential fractures and other conditions within a 4-hour period. The Plan denied your request.
The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 radiologic examination, chest (71045) transportation of portable X-ray equipment and personnel to home or nursing home (R0070) set-up portable x-ray equipment (Q0092) provided on January 13, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99070) provided to you on November 11, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says an appropriate procedure code was not billed.

The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. 

We looked at the file and Medicare rules. Code 99070 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for code 99070. 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 the services (99070) provided to you on November 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the services should be approved. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.