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

We decided that the Plan does not have to pay for the subsequent nursing facility care and eligible clinician attesting to documenting in the medical record they obtained, updated, or reviewed provided on December 26, 2019 by an OON provider.

You asked the Plan to pay for the subsequent nursing facility care and eligible clinician attesting to documenting in the medical record they obtained, updated, or reviewed. You say that the enrollee was seeking primary care through your providers, since they are able to come treat the enrollee in her place of long-term care, since she is physically unable to leave in order to seek primary care. The Plan denied your request. The Plan says the services were rendered by a non-participating provider. The Plan also says that prior authorization was not obtained.

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 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 subsequent nursing facility care and eligible clinician attesting to documenting in the medical record they obtained, updated, or reviewed provided on December 26, 2019 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
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 a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you underwent chemotherapy and radiation in August of 2020. You have difficulty walking longer distances outside the home. The records do not show that you require positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for frequent or an immediate change in body position or special attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital bed is not 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 semi-electric hospital bed.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Perjeta and Herceptin provided on January 12, 2021. 
 
You asked the Plan to pay for Perjeta, injection, pertuzumab, 1 mg (J9306), and Herceptin, Injection, 
trastuzumab, excludes biosimilar, 10 mg (J9355). You say that the drugs were medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the drugs in this setting have not been 
demonstrated in the peer-reviewed literature. 
 
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 pay for Perjeta, Injection, pertuzumab, 1 mg  
(J9306), and Herceptin, Injection, trastuzumab, excludes biosimilar, 10 mg (J9355). Our reviewer says that the 
drugs are not medically reasonable and necessary. Our physician reviewer found per compendia and literature 
there is no role of Herceptin and Perjeta in pancreas cancer, even if HER2/neu overexpressed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Perjeta, Injection, pertuzumab, 1 mg  (J9306), and Herceptin, Injection, 
trastuzumab, excludes biosimilar, 10 mg (J9355) have not been met. Therefore, we decided that the Plan does 
not have to pay for Perjeta and Herceptin provided on January 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography angiography (CTA) of the abdomen.

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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found you have diabetes, coronary artery disease, and peripheral vascular disease. The records do not support that the CTA is reasonable or medically necessary. There are no documentation indications for the scan. 

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 computed tomography angiography (CTA) of the abdomen.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and the emergency ambulance transport (A0427) provided on September 6, 2020.
You asked the Plan to pay for the transportation services. You say that the hospice and Medicare have denied this account. You also say that you feel you have been properly reimbursed for services rendered and no refund will be issue. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.
The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and the emergency ambulance transport (A0427) provided on September 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-preferred brand of glucose monitor test strips.
You asked the Plan to pre-approve a non-preferred brand of glucose monitor test strips. You say that the enrollee needs test strips. The Plan denied your request. The Plan says the requested brand of test strips is not covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. You have not documented that the requested brand of test strips is necessary to avoid an adverse medical outcome and you say you would like to switch the enrollee to one of the preferred products. Based on this information, we decided that Medicare rules for coverage of a non-preferred brand of glucose monitor test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve a non-preferred brand of glucose monitor test strips.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 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 daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. 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 skilled nursing facility (SNF) care
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), intraoral
periapical radiographic images (D0220, D0230), and an unspecified preventive procedure (D1999) provided on
September 18, 2020.
You asked the Plan to pay for a comprehensive oral evaluation, intraoral periapical radiographic images, and an
unspecified preventive procedure. You say that you told the provider you only wanted services that would be
covered. The Plan denied your request. The Plan says the comprehensive oral evaluation is a covered benefit,
but you have exceeded the frequency limit of one every 3 years. The intraoral periapical radiographic images,
and an unspecified preventive procedure are not covered benefits.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, intraoral periapical radiographic images, and an unspecified
preventive procedure have not been met. Specifically, the record shows that you had exceeded the frequency
limit for the comprehensive oral evaluation prior to this service on March 16, 2018. Additionally, intraoral
periapical radiographic images, and an unspecified preventive procedure are not covered benefits. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), intraoral periapical
radiographic images (D0220, D0230), and an unspecified preventive procedure (D1999) provided on
September 18, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest.
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. Medicare rules say that CT 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has dysphagia and underwent an upper endoscopy. The enrollee was found to have gastric varices of unknown etiology and severe gastritis. The medical records provided are insufficient to establish the medical reasonableness or necessity of the requested CT scan. 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 computed tomography (CT) scan of the chest.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 28, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on July 28, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve percutaneous left atrial appendage closure (LAAC) with endocardial implant (Watchman procedure).

You asked the Plan to pre-approve Watchman procedure. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because the Watchman procedure is designed as a second line of treatment when someone cannot take long-term oral anticoagulants.

The Plan follows Medicare rules. Medicare rules state that percutaneous LAAC may be covered through coverage with evidence development under certain 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 Watchman procedure. Our reviewer says that the enrollee meets the Medicare criteria for percutaneous LAAC (Watchman procedure). Our physician reviewer found the enrollee requires anticoagulation based on his combination of atrial fibrillation and elevated CHA2DS2VASc score. He has had several spontaneous vitreous bleeds recently with no clear source and is felt to now be a high-risk candidate for continued anti-coagulation. He will take anti-coagulation in the peri-procedural period, but the plan is to ultimately to discontinue anticoagulation long-term due to the recurrent eye bleeding issues. He has a significant contraindication to anti-coagulation, an elevated CHA2DS2VASc score and has undergone a well-documented evaluation with shared decision making by a non-implanting physician. He is now felt to be a good candidate with clear indications for the procedure to be done by a qualified physician, and a plan to eventually discontinue anti-coagulation based on the standard post procedure protocol of short-term peri-procedural anti-coagulation only. He therefore meets all necessary CMS criteria and rules for the implantation of the Watchman left atrial appendage occluder device.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Watchman procedure have been met. Therefore, we decided that the Plan has to pre-approve percutaneous left atrial appendage closure (LAAC) with endocardial implant (Watchman procedure).

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on March 22, 2021.

You asked the Plan to pay for the CT scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.

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, we have confirmed that code 70450 for the CT scan has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan provided on March 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Flex walk system.

You asked the Plan to pre-approve a Flex walk system. 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 follows Medicare rules. Medicare rules say that a determination of the type of foot for the prosthesis will be made by the treating practitioner and/or the prosthetist based upon the functional needs of the beneficiary. Basic lower extremity prostheses include a SACH foot. Other prosthetic feet are considered for coverage based upon functional classification.

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 Flex walk system. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested flex-walk system exceeds your functional need per the LCD L33787. The documentation does not support that you are a K3 ambulator given the documentation of using a walker for longer distances, multiple comorbidities, and shortness of breath with exertion.

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 Flex walk system have not been met. Therefore, we decided that the Plan does not have to pre-approve a Flex walk system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for fillings (D2393 x2) provided on March 16, 2021.

You asked the Plan to pay for fillings. You say that the service was medically necessary. The Plan denied your request. The Plan says the service at issue is not a covered benefit.

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 fillings (D2393 x2) provided on March 16, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve admission to an out-of-network (OON) inpatient rehabilitation facility (IRF).

You asked the Plan to pre-approve admission to the OON IRF. You say that that the in-network facility that was approved by the Plan is further away than the out-of-network facility, and it is important for the enrollee's mental health that their family is close by. It is more difficult for the family to participate in caring for the enrollee and providing social support at the out-of-network facility. The Plan denied your request. The Plan says that the necessary inpatient rehabilitation services can be provided at an in-network facility, which has already been approved by the Plan. The Plan only covers out-of-network services in limited circumstances, such as in an emergency or when the necessary care is not available in-network. While the in-network facility may be further away from the enrollee's family, it is not an unreasonable distance away according to Medicare standards.

Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The Plan says that enrollees must use contract providers. 

The requested IRF is not contracted with the Plan. In order for an acute inpatient facility in the enrollee's county of residence to be considered accessible by Medicare standards, it must be within both 45 minutes and 30 miles of the enrollee's residence. The Plan says that the approved in-network IRF is accessible. However, we were able to determine that the in-network IRF that was approved by the Plan is not within both 45 minutes and 30 miles of the enrollee's residence. We were able to confirm that the Plan does not have contract providers located within reasonable distance and travel time from your home who can provide admission to the OON IRF. Under Medicare rules, this means that contract providers are not accessible to you. Therefore, we decided that the Plan has to pre-approve admission to the requested out-of-network (OON) inpatient rehabilitation facility (IRF).

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 pre-approve proton beam radiation therapy.
You asked the Plan to pre-approve proton beam radiation therapy. You say that the enrollee is enrolled in a
clinical trial and this should be approved. The Plan denied your request. The Plan says the Plan is not
responsible for clinical trial services.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in
Original Medicare and the plan cost-sharing for the same services.
In this case, you asked the Plan to pre-approve proton beam radiation therapy as part of a clinical trial. The
Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan
does not have to pre-approve proton beam radiation therapy.