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

We decided that the Plan does not have to pre-approve physician's services to be provided by the requested out-of-
network provider.
You asked the Plan to pre-approve the physician services. The Plan denied your request. The Plan says you
must use network providers to get medical care and services when there are network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the requested out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee arthroscopy surgery provided on July 15, 2020.You asked the Plan to pay forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the service is not payable as the provider is not eligible for payment according to Medicare rules.The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners.Additionally, although the taxonomy for this National Provider Identifier (NPI)number is for a Physician assistant, neither the NPI database shows an active Physician Assistant license for this provider. Therefore, we decided that the Plan does not have to pay forthe knee arthroscopy surgery provided on July 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interim partial denture (D5820).You asked the Plan to pre-approve an interim partial denture. You say that you want the Plan to pay for the service at issue.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 pre-approve an interim partial denture (D5820).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean electrical bone growth stimulator (BGS) coded as E0747.You asked the Plan to pre-approvethe requested BGS. You say that this needs to be approved as without use of this device the enrollee risks amputation.The Plan denied your request. The Plan says the criteria for coverage of the requested stimulator have not been met.The Plan must follow Medicare rules. Medicare rules say that an electrical BGS is covered for treatment of a failed fusion of a joint other than in the spine where a minimum of nine months has elapsed since the last surgery.In this case, the fusion surgery took place on November 5, 2020. Nine months have not passed since the last surgery for this joint. As such, the Medicare coverage criteria have not been met.Therefore, we decided that the Plan does not have to pre-approvean electrical bone growth stimulator(BGS) coded as E0747
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveMyoPro Orthotic device (L8702) to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe orthotic device. You say that given that traditional rehab strategies have failed, the enrollee's family physician referred him for myoelectric orthotic restoration using the MyoPro Motion G orthosis in question.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Myopro is considered investigational and unproven and not a covered benefit. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.The rules also say that experimental and investigational devices are not covered.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan saysthat 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 thePlan. 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-approveMyoPro Orthotic device (L8702) to be provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on August 13, 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 procedure code 97110 is not supported.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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows that the services were performed in the home health or hospice setting and there is a more appropriate code for these services. 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 pay for the physical therapy services rendered on August 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the total electric hospital bed.You asked the Plan to pre-approve the total electric hospital bed. You say that the records provided should support the necessity of the service in dispute.The Plan denied your request. The Plan says this item 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 the total electric hospital bed
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvenon-sterile gloves (A4927).You asked the Plan to pre-approvenon-sterile gloves. You say that you are unable to hold your urine at times and uses gloves to wash yourself several times a day because you are unable to shower as frequently.The Plandenied your request. The Plan says this 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.Therefore, we decided that the Plan does not have to pre-approvenon-sterile gloves (A4927).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided from September 10, 2020, through September 15, 2020.

You asked the Plan to pay for the continued inpatient care. You say that it is felt that this hospital stay was medically necessary and should be paid. The Plan denied your request. The Plan says as of 10AM on September 10, 2020, the enrollee was stable for transfer. The facility did not request authorization for post-stabilization care which could have been provided in-network.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the continued inpatient care. Our reviewer says that the enrollee was stable for transfer as of the morning of September 10, 2020, and continued inpatient care was unauthorized post-stabilization care. Our physician reviewer found the enrollee is an 84-year-old woman with a history of stroke, diabetes, and hypertension, who presented to the hospital on 6/8/20 with altered mental status and hypoxemia. The enrollee was diagnosed with pneumonia. The Plan has approved coverage for care provided up to 10 AM on 9/10/20. 

The treating physician did not document that the patient was not stable for transfer. The available documentation in the case file supports that the enrollee was stable for transfer by ambulance to an in-network hospital on 9/10/20 at 10 AM. 

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 continued inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided from September 10, 2020, through September 15, 2020.
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 would benefit from care in the LTACH setting. The Plan denied your request. The Plan says care can be provided in the current facility.
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 the patient is a 67-year-old male who was admitted to the current acute care hospital with osteomyelitis and associated chronic left foot wounds and left leg pain. He was treated with incision and drainage and 5th toe amputation as well as wound vac and antibiotics. Recent notes show the wound was bleeding which needed controlling. He remained hemodynamically stable. The patient is more stable and improving and only requires short-term acute care hospital need which can safely be administered at the current facility. 2. There are no services at the LTACH that the patient requires that are not already available at the current facility.
Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may be considered when treatment has completed. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.
You asked the Plan to pre-approve Aranesp. You say that the medication is 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 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 Aranesp. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the enrollee has multifactorial anemia. He is listed as having anemia of chronic kidney disease, blood loss, and secondary to chemotherapy. There are no iron studies provided. Any iron deficiencies would need to be corrected prior to initiation of Aranesp. The service is 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 Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on January 27, 2021.
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says it is important to know which providers are part of our network because, with limited exceptions, while you are a member of our Plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.
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 hearing aids. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided by an out-of-network provider on August 4, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 payThe 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 inthis 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 forthe services provided by an out-of-network provider on August 4, 2020. for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intensity-modulated radiation therapy (IMRT) with LDR Brachytherapy boost.

You asked the Plan to pre-approve intensity-modulated radiation therapy (IMRT) with LDR Brachytherapy boost. You say that the requested intensity-modulated radiation therapy (IMRT) with LDR Brachytherapy boost is medically necessary. The Plan denied your request. The Plan says the requested intensity-modulated radiation therapy (IMRT) with LDR Brachytherapy boost 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 intensity-modulated radiation therapy (IMRT) with LDR Brachytherapy boost. Our reviewer says that the requested intensity-modulated radiation therapy (IMRT) with LDR Brachytherapy boost is not medically necessary. Our physician reviewer found at issue for this enrollee is the need for combination brachytherapy (as a boost) and external beam radiation. Using combined modality treatment vs single modality treatment is arguably more aggressive and much better studies for patients with intermediate- or high- risk disease as opposed to this enrollee with low-risk disease.

Even among patients with higher risk disease, the use of combined modality treatment vs. single modality (brachytherapy alone or external beam radiation alone) is controversial.

Because of the lack of survival benefit with the addition of brachytherapy to IMRT, it remains somewhat controversial within the field. From the principles of radiation therapy section, the NCCN guidelines state that a brachytherapy boost in men with intermediate and high-risk prostate cancer has demonstrated an improved biochemical control, but with greater toxicity.

The most recent NCCN guidelines include, as treatment options for unfavorable intermediate risk prostate cancer, external beam radiotherapy + brachytherapy +/- androgen deprivation therapy for patients with expected survival greater than 10 years. However, for low-risk prostate cancer, or favorable intermediate risk, and survival expected greater than 10 years, the NCCN guidelines recommend external beam radiotherapy alone or brachytherapy alone.

The ASTRO model policy does not specifically address brachytherapy as a boost for prostate cancer.

Based on expert guidelines (NCCN, AUA/ASTRO/SUO), I would not consider the treatment to be furnished in accordance with accepted standards 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 intensity-modulated radiation therapy (IMRT) with LDR Brachytherapy boost have not been met. Therefore, we decided that the Plan does not have to pre-approve intensity-modulated radiation therapy (IMRT) with LDR Brachytherapy boost.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walker (E0143, S9999) provided August 19, 2020.
You asked the Plan to pay for the walker. You say that this type of walker was medically necessary. The Plan denied your request. The Plan says the was obtained from a supplier that does not participate in the Medicare program.
The Plan must follow Medicare rules. Medicare rules say that a provider or supplier must be enrolled in the Medicare program. We looked at the file and Medicare rules. The walker was ordered from Amazon.com. Amazon.com does not participate in the Medicare program. Based on this information, we decided that Medicare rules for coverage of the walker have not been met. Therefore, we decided that the Plan does not have to pay for a walker (E0143, S9999) provided August 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided September 17, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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. We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the claim form (81, laboratory) does not match the place of service detailed in the records (11, office setting). 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 lab services (G0483) provided September 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on January 25, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you, nor the plan, should have to pay the $90.50 that you are being charged. The Plan denied your request. The Plan says the claim processed correctly.
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 $90 copayment for Emergency Care.
You have been asked to pay $90 copayment for the emergency room visit. the emergency room visit falls within the Emergency Care 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 emergency room visit provided on January 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 by an out-of-network provider on November 3, 2020.