Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954) provided on November 20, 2020.

You asked the Plan to pay for the prefabricated post and core. You say that you believe this service should be covered. The Plan denied your request. The Plan says this service is not covered.

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. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954) provided on November 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fludarabine Phosphate, Cyclophosphamide, and
Ondansetron.

You asked the Plan to pre-approve the requested drug regimen. The Plan denied your request. The Plan says
the requested use of the drugs does not meet criteria.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA approved
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 the requested drug regimen. Our
physician reviewer found that in this case, the enrollee is being treated for Waldenstrom macroglobulinemia.
The Medicare approved compendia to not support the prescribed regimen. No literature from Medicare
approved cancer journals was submitted in support of the request. The documentation does not 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 the requested drug regimen have not been met. Therefore, we decided that the
Plan does not have to pre-approve Fludarabine Phosphate, Cyclophosphamide, and Ondansetron.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable home ventilator.

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 medically necessary.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.

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 you do not meet the criteria for coverage. Our physician reviewer found the records show that you have obstructive sleep apnea (OSA) and worsening of chronic obstructive pulmonary disease (COPD). You do not have chronic respiratory failure. There is insufficient documentation to show that the current BiPAP machine is not appropriate for your condition. The portable ventilator is 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 pre-approve a portable home ventilator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 18, 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 testing is not covered.

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 test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 18, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does not require daily skilled care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 pre-approve SNF services. Our physician reviewer found that the enrollee presented to the acute hospital with weakness, confusion, and severe dementia. She is walking 200 feet with a two wheeled walker with contact guard to minimal assistance and is contact guard to minimal assistance for transfers. She is reported to have deficits with performing activities of daily living but details of the level of assistance needed is not provided in the available records. There is no documentation that she requires skilled services of a skilled professional nurse to provide medically necessary and reasonable treatment. Although the enrollee does require services of a qualified therapist, the services do not need to be provided on a daily basis. She does not require the services on an inpatient basis, only in a skilled nursing facility 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide an intermittent limb compression device.

You asked the Plan to provide pneumatic compressor, segmental home model without calibrated gradient pressure (E0651) and segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667). You say that daily home compression pump therapy is warranted at this time in order to maintain proper management of the enrollee's chronic condition. The Plan denied your request. The Plan says there are no detailed measurements confirming lymphedema.

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.

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 provide pneumatic compressor, segmental home model without calibrated gradient pressure (E0651) and segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667). Our reviewer says that is not medically necessary. Our physician reviewer found the case file does not contain detailed measurements over time confirming the persistence of the lymphedema.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pneumatic compressor, segmental home model without calibrated gradient pressure (E0651) and segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667) have not been met. Therefore, we decided that the Plan does not have to provide an intermittent limb compression device.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from February 12, 2020 to February 27, 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 claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home health services under a plan of treatment. 

We looked at the file and Medicare rules. The file shows that the claims were not billed with the correct TOB code. Therefore, we decided that the Plan does not have to pay for the home health services rendered from February 12, 2020 to February 27, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Fulphila 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 that the regimen has a low risk of febrile neutropenia.

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 medically reasonable and necessary. Our physician reviewer found growth factor support such as with Fulphilia is considered a standard of care in patients with more than 20% risk of neutropenic fever. The enrollee meets the criteria based on several factors. The most important patient-specific risk factor for the development of FN is older age (65 years or older). Other identified risk factors that might prompt the use of prophylactic G-CSF include prior exposure to chemotherapy, prior radiation therapy, persistent neutropenia, (he would have been due for cycle 3 of chemotherapy but had neutropenia) poor performance status, and HIV infection. The use of fulphilia 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 the drug have been met. Therefore, we decided that the Plan has to pre-approve Fulphila for the enrollee.

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: 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 October 29, 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 October 29, 2020.
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 enrollee's needs cannot be safely met at a lower level of care. You say that the enrollee meets the criteria for coverage of IRF care. The Plan denied your request. The Plan says IRF care 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 was admitted for cervical spine surgery, neck hematoma and respiratory failure. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation trips.

You asked the Plan to provide additional transportation. You say that you need additional trips for therapy because you are unable to drive due to a medical condition. The Plan denied your request. The Plan says the routine transportation benefit is limited to 48 one-way rides to health care related locations other than your primary care provider's office. There is no exception that would allow for additional rides.

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 48 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a reclining mattress.

You asked the Plan to pre-approve a reclining mattress. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Review of the file shows that the prescription provided from the provider was for a rental of a hospital bed and mattress. The purchase of a new mattress is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve a reclining mattress.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment with a Sanexas device reported on September 2, 2020.

You asked the Plan to pay for the 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 CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. 

We find that CPT code 97016 is 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. Based on this information, we decided that Medicare rules for coverage of the treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the treatment with a Sanexas device reported on September 2, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve continued inpatient hospital care after May 18, 2021 for the enrollee.

You asked the Plan to pre-approve continued inpatient care. You say that these services are medically necessary. The Plan denied your request. The Plan says that that the request is not medically necessary because the records received show that the enrollee's condition has improved and is awaiting placement in a skilled nursing facility.

The Plan must follow Medicare rules. Before discharging an enrollee from an inpatient hospital level of care, Medicare rules say that the Plan must obtain concurrence from the physician who is responsible for the enrollee's inpatient care. 

In this case, the record does not show that the physician responsible for the enrollee's inpatient care concurs with this discharge. Therefore, we decided that the Plan has to pre-approve continued inpatient hospital care after May 18, 2021 for the enrollee.

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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (99285) provided on September 19, 2020.

You asked the Plan to pay for an emergency room visit. You say that this was billed correctly. The Plan denied your request. The Plan says 99284 is more appropriate for the services rendered.

The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect the services provided.

In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the evaluation and management of a patient which requires three components (taking into account the urgency of the clinical condition or the patient's mental status):

1. a comprehensive history; 
2. a comprehensive examination; and 
3. medical decision making of high complexity.

In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate significant threat to life or physiologic function.

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 an emergency room visit Our reviewer says that the criteria for payment of 99285 have not been met. Our reviewer found based on the records provided, the patient did not have a severe, life-threatening clinical condition that would meet criteria for the 99285 code.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an emergency room visit have not been met. Therefore, we decided that the Plan does not have to pay for an emergency room visit (99285) provided on September 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital
bed.