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

We decided that the Plan does not have to waive the coinsurance for multianalyte assay procedure with algorithmic analysis (CPT code 81599) provided on December 16, 2020, by an out-of-network provider.
You asked the Plan to waive the coinsurance for the laboratory services. You say that you did not know the provider was out-of-network. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received laboratory services on December 16, 2020, by an out-of-network provider. You have been asked to pay 30% coinsurance of the allowed amount for the laboratory services. The allowed amount is $7,193 The total you owe is $2,157.90 ($7,193 x 30% = $2,157.90). Your 2020 EOC states
that enrollees must pay 30% coinsurance for out-of-network Medicare-covered lab tests. 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 coinsurance for multianalyte assay procedure with algorithmic analysis (CPT code 81599) provided on December 16, 2020, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan (78816).

You asked the Plan to pre-approve a PET scan. You say that this is medically necessary. The Plan denied your request. The Plan says this use of a PET scan is not covered.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically 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 a PET scan. Our reviewer says that the requested PET scan is not medically necessary. Our physician reviewer found PET scans are not covered for staging regional nodes. There is no indication to look for metastasis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan (78816).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept Procedure.
You asked the Plan to pre-approve the Intracept Procedure. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Intracept Procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Intracept Procedure is an experimental/investigational procedure. Therefore, the request is considered 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 the Intracept Procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept Procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on September 23, 2020, and October 21, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on September 23, 2020, and October 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous lumbar spinal distraction device
insertion.
You asked the Plan to pre-approve Insertion of interlaminar/interspinous process stabilization/distraction
device, without open decompression or fusion, including image guidance when performed, lumbar; single level
(22869). You say that the enrollee has tried and failed conservative therapy. The Plan denied your request. The
Plan says research has not found this procedure to be helpful for the enrollee's condition.
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 Insertion of interlaminar/interspinous
process stabilization/distraction device, without open decompression or fusion, including image guidance when
performed, lumbar; single level (22869). Our reviewer says that the requested items/services are not considered
medically reasonable and necessary in this case. Our physician reviewer found interlaminar spacer devices and
spinous process spacer devices remain experimental. More research is needed to show safety and efficacy of
the devices.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Insertion of interlaminar/interspinous process stabilization/distraction device,
without open decompression or fusion, including image guidance when performed, lumbar; single level
(22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous
lumbar spinal distraction device insertion.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana inhalation solution.
You asked the Plan to pre-approve Brovana inhalation solution. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
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 Brovana inhalation solution. Our reviewer says that the documentation does not support that the ernollee meets step therapy criteria. Our physician reviewer found the enrollee has had persistent shortness of breath despite treatment with multiple inhaler and oral therapies. The documentation does not support that the enrollee has tried and failed Perforomist. The documentation does not support that Perforomist would likely be less effective and/or likely have adverse effects 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 Brovana inhalation solution have not been met. Therefore, we decided that the Plan does not have to pre-approve Brovana inhalation solution.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the brand specific female external catheter.

You asked the Plan to pre-approve the brand specific female external catheter. You say that Medicare covers this catheter. The Plan denied your request. The Plan says this external catheter is not covered by Medicare.

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 brand specific female external catheter. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no peer-reviewed articles published in the medical literature specific to the brand specific female external catheter, or external urinary collection system using a continuous low-pressure pump. Thus, there is no evidence to show the brand specific female external catheter to be an effective alternative in managing urinary incontinence.

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 brand specific female external catheter have not been met. Therefore, we decided that the Plan does not have to pre-approve the brand specific female external catheter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of inpatient skilled nursing facility 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 care. Our reviewer says that inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that the enrollee does not require skilled nursing or skilled therapy services on a daily basis. As a practical matter, the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the walking boot (L4361) provided September 28, 2020.
You asked the Plan to waive the copayment for the walking boot. You say that you would like this coinsurance waived. The Plan denied your request. The Plan says the coinsurance has processed correctly in this case.
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 20% coinsurance for durable medical equipment. You have been asked to pay a total cost share of $45.39 for the walking boot ($226.29 Medicare allowed amount x 20% coinsurance). This item falls within the durable medical equipment benefit category. 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 walking boot (L4361) provided September 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and Segmental pneumatic appliance (E0667).
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you ask for reversal of the denial after review of the enclosed documents as this enrollee has demonstrated a medical need and a unique clinical condition, which meets the criteria of the provider. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and Segmental pneumatic appliance (E0667).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic nuclear medicine to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve diagnostic nuclear medicine. You say that you would like approval for these services to be provided by an out-of-network provider. The Plan denied your request. The Plan says there are in-network providers available for these services.

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 diagnostic nuclear medicine to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve specialist services. You say that you would like approval to see this retinal specialist. The Plan denied your request. The Plan says there are in-network providers available for these services.

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 specialist services to be provided by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveHyalgan Supartz.You asked the Plan to pre-approveHyalgan Supartz. You say that the requested drug is medically necessary for the enrollee's condition.The Plandenied your request. The Plan says step therapy criteria have not been met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Hyalgan Supartz. Our reviewer says that step therapy criteria have not been met. Our physician reviewer found that the patient is a 65-year-oldfemale with bilateral knee pain who has failed exercises, bracing, Cortisone injection, Voltaren, Icy Hot, and for which NSAIDs were contraindicated due to Coumadin use. The provided records did not reveal that the patient had tried and failed the Plan's required step therapy drugs OrthoVisc, SynVisc, or SynVisc-One. Current evidence compares all available hyaluronic acid injections and found them to be essentially equal in safety and effectiveness. There is no expectation that the patient would likely have a less effective or poorer outcome if they tried the proposed alternatives listed above.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyalgan Supartz have not been met.Therefore, we decided that the Plan does not have to pre-approveHyalgan Supartz.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo.
You asked the Plan to pre-approve Opdivo. You say that the requested Opdivo is medically necessary. The Plan denied your request. The Plan says the requested Opdivo is 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 Opdivo. Our reviewer says that the requested Opdivo is not medically necessary. Our physician reviewer found the enrollee is diagnosed with metastatic gastric cancer. The requested use of Opdivo is not FDA-approved for the enrollee's diagnosis. Approval is for combination therapy and not as a single agent. The requested use of Opdivo is not supported by any of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The enrollee has progressed on prior immunotherapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the screening breast tomosynthesis provided on July 22, 2020, billed
with code 77063.
You asked the Plan to pay for the billed screening breast tomosynthesis. You say that code 77063 was denied
as duplicate, but no Explanation of Benefits was issued with either payment or denial of this code. The Plan
denied your request. The Plan says that proof has been provided that payment was made for code 77080, so this
was correctly denied as duplicate. Code 77063 is being handled under separate case.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan issued a denial of payment for code 77063 with the denial reason that
this service was already paid to another provider. However, the Plan has not provided any evidence to support
this. The Plan did not provide proof of payment of this service to another provider, nor did the Plan offer an
alternate valid denial rationale. Payment was also made for the technical component of the screening
mammogram that was provided on this same date which supports payment of the add-on code 77063. We find
that the denial of payment for this code has not been substantiated. Therefore, we decided that the Plan has to
pay for the screening breast tomosynthesis provided on July 22, 2020, billed with code 77063.
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: 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 services are necessary The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do 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 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.