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

We decided that the Plan does not have to pay for the a thyroid uptake study (78012, A9516) provided on July 22, 2019.
You asked the Plan to pay for the thyroid study.. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not preauthorized or emergent. There were network providers available.
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 has network providers available who can provide 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 a thyroid uptake study (78012, A9516) provided on July 22, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for chemotherapy administration services provided to the enrollee on July 12, 2019.
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 that the documentation submitted did not support the units 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 CPT Code Manual definition of code 96415 is "Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure)." 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 the services. Our reviewers says that the services at issue in this case were billed correctly. Our physician reviewer found the documentation indicates that the enrollee received Rituxan. The total dose administered was 760mg/760ml. The rate of infusion was increased approximately every 30 minutes. While the start time of each infusion rate is noted, the stop time is not. However, the stop time of the first three infusion rates can be assumed to be the start time of the next infusion rate. The stop time of the final infusion rate can be calculated based on the volume remaining to be infused following the first three infusion rates. Given that the first three rates infused 319mls, the final rate had to infuse 441mls. At a rate of 400ml/hr that would have taken 66.25mins. Combing the times of all four infusions is 165.25mins, which is equal to 2.25hours. Therefore the billing of an initial hour of infusion, followed by two subsequent hours of infusion is supported. 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 services have been met. Therefore, we decided that the Plan has to pay for chemotherapy administration services provided to the enrollee on July 12, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from November 11,
2019 to November 17, 2019 and November 26, 2019 to December 4, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's
condition no longer required daily skilled services at an inpatient skilled nursing facility (SNF) level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is 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 pay for the skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
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 skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from November 11, 2019 to November 17,
2019 and November 26, 2019 to December 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa(J7323).You asked the Plan to pre-approve the Euflexxa. You say that Euflexxa is medically necessary.The Plan denied your request. The Plan says a trial of Orthovisc and Monoviscis required before alternatives can be considered.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 Euflexxa. Our reviewer says that coverage criteria has not been met. Our physician reviewer found while the record shows that Orthovisc provided no relief for the enrollee, there was no documented trial of Monovisc or any reason why it would be contraindicated 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 Euflexxa have not been met.Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns for tooth #'s 4 & 6 and a pontic for tooth
#5.
You asked the Plan to pre-approve the retainer crowns and pontic. You say that the enrollee complained of his
inability to chew properly. You also say that a fixed bridge is recommended due to the enrollee's unstable
restorations of tooth #'s 4 & 6 as well as his dexterity concern. The Plan denied your request. The Plan says the
documentation does not say why a denture cannot be used to replace the enrollee's missing teeth.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the retainer
crowns and pontic when the services are medically necessary and reasonable.
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 retainer crowns and pontic. Our
reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee recently
lost tooth #5 and had previously restored tooth #'s 4 & 6. There is no opposing tooth to #4. Our reviewer found
that the provider noted that the enrollee had voiced concerns over their ability to manage a partial denture,
however, there has been no documentation of a physical or neurological disorder that preclude placement of a
removable prosthesis.
Although a fixed prosthesis is a reasonable alternative treatment plan, coverage is limited to particular
circumstances. Without adequate documentation of a physical or neurological disorder, the Plan does not allow
for coverage for a fixed prosthesis. Our physician reviewer also found that given the records supplied, there is
no finding of medical necessity for the requested procedure.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the retainer crowns and pontic have not been met. Therefore, we decided that
the Plan does not have to pre-approve retainer crowns for tooth #'s 4 & 6 and a pontic for tooth #5.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services (CPT 19301, CPT 38525)
provided on October 2, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
medically necessary.
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment
restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to
establish medical necessity. In this case, you billed assistant surgery services for CPT code 19301. The
Medicare Fee Schedule Database contains a surgical indicator of 0 for this procedure.
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 the services. Our reviewer says that the
assistant surgeon services were not medically reasonable and necessary for CPT 19301. Our physician reviewer
found that the documentation in the case file does not support patient and procedure characteristics which
necessitated the services of an assistant surgeon. 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 services have not been met.
Additionally, Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon
services are not covered. In this case, you billed assistant surgery services for CPT code 38525. The Medicare
Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has
determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this
information, we find that Medicare coverage criteria for the services have not been met. Therefore, we decided
that the Plan does not have to pay for the assistant surgeon services (CPT 19301, CPT 38525) provided on
October 2, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve One Touch Ultra Test Strips for the enrollee. You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that there is no documentation why this is medically necessary. The Plan must follow Medicare rules. Medicare rules say that plans may limit enrollees to preferred providers. The items at issue are One Touch Ultra Test Strips. One Touch Ultra Test Strips are not a preferred provider with the Plan for diabetic supplies. Roche or Trividia Health are the preferred providers. Therefore, we decided that the Plan does not have to pre-approve One Touch Ultra Test Strips for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-preferred diabetic testing strips, One Touch Verio test strips.You asked the Plan to pre-approve the non-preferred diabetic testing strips. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested diabetic testing supplies can be provided from a preferred provider.Medicare rules say that plans can require enrollees to get care from preferred brands. The contract with the Plan says that the Plan has to pre-approve care from preferred brands only in cases involving emergencies, out of area urgent care and care that cannot be provided by preferred brands.The requested brand in this case is not a preferred brand with the Plan. The Plan has preferred brands 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 non-preferred diabetic testing strips, One Touch Verio test strips.We note that the plan has approved 90 days worth of the One Touch Verio test strips to help transition to the plan's preferred brands.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health services.
You asked the Plan to pre-approve inpatient mental health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
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 services. Our reviewer says that the documentation does not support that the requested inpatient mental health services are medically reasonable or necessary. Our physician reviewer found the enrollee was involuntarily admitted to the acute inpatient psychiatric hospitalization on May 3, 2020 with Major Neurocognitive Disorder Most Likely Due to Alzheimer's Disease with Behavioral Disturbance. The documentation does not support that the enrollee was expected to improve in a reasonable period of time beyond the dates in question as the enrollee was not showing any dangerousness to self or others without aggressive behaviors was awaiting placement. The enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as the enrollee was not a danger to himself or others and did not have any illusions, auditory or visual hallucinations. Therefore, the enrollee does not meet criteria for the requested services and could be treated in a lesser restrictive setting as the enrollee was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour test strips.
You asked the Plan to pre-approve Contour test strips. You say that you would like the plan to reconsider their
denial The Plan denied your request. The Plan says the requested type of supply is not a covered benefit.
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 specific vendors for diabetic testing supplies only.
The requested brand of test strips are not a preferred vendor with the Plan. The Plan has preferred vendors
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
Contour test strips.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for eye refraction services provided on September 30, 2019. You asked the Plan to pay for the eye refraction services. You say that you are appealing denial of payment because you received a routine eye exam and glasses. You did not get a refraction and you don't know what that is. The Plan denied your request. The Plan says that the refraction was performed without an eye exam and is therefore not covered. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 1 supplemental routine eye exam (including eye refraction) per year. The plan has not provided any records or documentation that supports that the eye refraction was not a part of a routine eye exam. We looked at the file and the Plan's rules. The refraction was performed without an eye exam and is therefore not covered. Based on this information, we decided that the Plan's rules for coverage of the eye refraction services have been met. Therefore, we decided that the Plan has to pay for eye refraction services provided on September 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve coverage of the warranty on the remote battery for a spinal cord stimulator.
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 the services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that services that do not contribute meaningfully to the treatment of an illness or injury or the functioning of a malformed body member are not covered. We looked at the file and Medicare rules. The services at issue are a warranty for a remote battery. These services are not covered by Medicare because they do not contribute meaningfully to the treatment of an illness or injury or the functioning of a malformed body member. Therefore, we decided that the Plan does not have to pre-approve coverage of the warranty on the remote battery for a spinal cord stimulator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis tablets.
You asked the Plan to pre-approve Eliquis tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Eliquis tablets are not covered under the enrollee's Medicare Part B benefit.
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 Eliquis tablets.
Benefits for Eliquis tablets 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve behavioral inpatient admission.
You asked the Plan to pre-approve behavioral inpatient admission. You say that you would like the plan to
reconsider their denial The Plan denied your request. The Plan says the requested services are not medically
necessary.
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 behavioral inpatient admission. Our
reviewer says that the documentation does not support that the requested behavioral inpatient admission is
medically reasonable or necessary. Our physician reviewer found you were involuntarily admitted to the acute
inpatient psychiatric hospitalization on May 5, 2020 with Schizophrenia Spectrum Disorder and Cocaine Use
Disorder. The documentation does not support that it was medically necessary and reasonable to have
psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates
in question, as you did not have any suicidal or homicidal thoughts, hallucinations or abnormal behaviors. The
documentation supports that the requested services could be treated in a lesser restrictive setting as you were
not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and were not
showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to
safety We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of behavioral inpatient admission have not been met. Therefore, we decided that the Plan does not have to pre-approve behavioral inpatient admission.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from September 25, 2019 to October 24, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee returned to his custodial setting at the SNF without skilled care ordered or received. The Plan also says that no skilled rehabilitation services were provided during this time frame.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from September 25, 2019 to October 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One injections. You asked the Plan to pre-approve Synvisc-One. You say that Synvisc is medically necessary. The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be approved. 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 Synvisc-One. Our reviewer says that rules for coverage have not been met. Our physician reviewer found the plan preferred drugs have not been trialed. The record does not show any reason why they would be contraindicated 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 Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One injections.