Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve epidural steroid injections (64483 and 64484).
You asked the Plan to pre-approve the epidural steroid injections. You say that you would like reconsideration because you are in pain and the last injections were helpful. The Plan denied your request. The Plan says no more than two transforaminal injections may be performed at a single setting.
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 epidural steroid injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bilateral transforaminal epidural steroid injections are not covered per the LCD. 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 epidural steroid injections have not been met. Therefore, we decided that the Plan does not have to pre-approve epidural steroid injections (64483 and 64484).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto Tab 49-51mg.You asked the Plan to pre-approveEntresto Tab 49-51mg. You say that the requested medication is necessary.The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.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-approveEntresto Tab 49-51mg.Benefits for Entresto Tab 49-51mgmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on January 8, 2020.
You asked the Plan to waive the copayment for the laboratory work. You say that you did not have a copayment for laboratory work in 2019. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment per visit for laboratory tests, non-radiological tests, diagnostic tests, flat film x-rays, and ultrasounds. You have been asked to pay a $15 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 laboratory work provided on January 8, 2020.
Our decision is only about the 2020 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygenator assembly and operation services (CPT 99190) provided to the enrollee on January 22, 2020.
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 payment for this service is the responsibility of the facility to any vendor.
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 99190 is "Assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring)." We find that CPT code 99190 is not supported in the medical record. Specifically, payment for this code would be included in the part-A DRG payment to the facilty. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for oxygenator assembly and operation services (CPT 99190) provided to the enrollee on January 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Capecitabine.
You asked the Plan to pre-approve Capecitabine. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered 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 drug requested here is only covered when used as a single agent or in combination of Trastuzumab product, Taxotere (docetaxel), Tykerb (lapatinib). Review of the file shows that you are requesting this drug for use with Keytruda. Keytruda is not listed as a drug that can be used in combination with the requested drug. Therefore, we decided that the Plan does not have to pre-approve Capecitabine.
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 records provided support the need for IRF care.The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the records do not show a need to be seen by a rehab doctor 3 times a week. The Plan says that the hospital records show that the enrollee's medical conditions have improved and that an inpatient rehab stay is not needed to get better.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 enrollee does not require the intensity of services provided at anIRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adult briefs.

You asked the Plan to pre-approve adult briefs. You say that these are medically necessary. The Plan denied your request. The Plan says that these are not covered by Medicare.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve adult briefs.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha.
You asked the Plan to pre-approve Repatha. The Plan denied your request. The Plan says for the request to be eligible for coverage, the medication must be supplied by the medical provider or medical facility.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication was dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Repatha.
Benefits for Repatha 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (64640).
You asked the Plan to pre-approve radiofrequency ablation. You say that that this is medically necessary. The Plan denied your request. The Plan says this is experimental.
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 radiofrequency ablation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/ investigational procedure. It is not the standard of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (64640).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the records provided support the need for IRF care. You say that a delay in coverage of IRF care will jeopardize the enrollee's chance fora full recovery. You say that the enrollee requires interdisciplinary therapy care, physical therapy, occupational therapy, and speech therapy.The Plan denied your request. The Plan says the records do not show that the enrollee is medically stable. The Plan say that the records do not show that the enrollee is able to participate in 3 hours of therapy daily, nor do they show that the enrollee requires an intensive team approach when able to transition to a lower level of care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental implant in lower arch.
You asked the Plan to pre-approve the implant. You say that this is medically necessary. The Plan denied your request. The Plan says there are currently teeth present in the lower arch.
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 implant 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 implant. Our reviewer says that the requested implants are not medically reasonable or necessary. Our physician reviewer found the policy documents specifically allow implant placement in cases that the implants would be placed in an edentulous arch to retain a full lower denture. In this case there are eleven remaining teeth in the lower arch that are not treatment planned for removal. There are no teeth posterior to tooth #29. You were given the option of root canal treatment for #19 or extraction. It appears that coverage of procedures was of paramount concern to you in determining treatment plans. Given there are remaining teeth in the lower arch, the policy limitations do not allow for individual implant placement to restore a single tooth. The requested procedures are not medically necessary in this instance under the plan. 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 implant have not been met. Therefore, we decided that the Plan does not have to pre-approve a dental implant in lower arch.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses (L3960, L3930) provided on January 8, 2020.
You asked the Plan to pay for orthoses. You say that the records clearly demonstrate necessity. The Plan denied your request. The Plan says no shipping documentation has been submitted.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. No delivery or shipping documentation was included in the file. Therefore, we decided that the Plan does not have to pay for orthoses (L3960, L3930) provided on January 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvegenicular (knee) nerve blocks.You asked the Planto pre-approvethe knee nerve blocks. You say that this would possibly be effective and should be allowed to relieve your pain.The Plandenied your request. The Plansaysthere are no peer-reviewed studies showing this treatment is safe and effective.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 knee nerve blocks. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery.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 knee nerve blocks have not been met.Therefore, we decided that the Plandoes not haveto pre-approvegenicular (knee) nerve blocks.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra eye drops.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for 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 Xiidra eye drops.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that it is felt that this enrollee should be treated in the LTACH setting.The Plan denied your request. The Plan says the enrollee is no longer requiring ICU level care and can remain in the current facility until stable for discharge to a lower level of care.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support with bronchodilators as needed, hemodialysis, surveillance laboratory studies, wound care, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the enrollee will benefit from extended medical and rehab care.The Plan denied your request. The Plan says the enrollee does not have a complex illness that needs further hospital care.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for injuries sustained in a recent car accident, colitis and alcoholism. The enrollee was transiently intubated/ventilated, but is no longer intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the percutaneous discectomy at L4-L5 under fluoroscopic guidance provided on February 21, 2020.
You asked the Plan to pay for the percutaneous discectomy at L4-L5 under fluoroscopic guidance. You say that the services provided were medically necessary. The Plan denied your request. The Plan says that the services provided were not medically necessary.
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. In this case, the Plan did not provide medical records for the procedure at issue to determine if the services were medically necessary. The Plan also did not provide a claim that included a billed amount that was denied for payment. Therefore, we decided that the Plan has to pay for the percutaneous discectomy at L4-L5 under fluoroscopic guidance provided on February 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle (POV).You asked the Plan to pre-approve a POV. You say that without a scooter you can't get out of your building.The Plan denied your request. The Plan says that you do not meet criteria for coverage.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle (POV).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Desoximetasone cream.
You asked the Plan to pre-approve Desoximetasone cream. You say that this medication improved the enrollee's condition. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.
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 Desoximetasone cream.
Benefits for Desoximetasone cream may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.