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

We decided that the Plan does not have to pre-approvethe insertion of a Superion interspinous stabilization device (22869, 22870).You asked the Plan to pre-approvethis service. You say that this service is medically necessary to treat lumbar spinal stenosis.The Plan denied your request. The Plan says this service 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the enrollee was being treated for spinal stenosis of the lumbar region with neurogenic claudication. Current evidence based medical guidelines and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. The Federal Food and Drug Administration (FDA) indications include the implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of "moderate" spinal stenosis. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. Detailed documentation is not evident regarding spinal instability on flexion/extension films. There is no documentation of the enrollee's height, weight or body mass index. There is imaging evidence of scoliosis of the lumbar spine, magnetic resonance imaging notes of rotatory dextrocurvature of the thoracolumbar spine and mild levoconvex curvature of the lower lumbar spine, with no documentation of the Cobb angle. There is no discussion indicating that a dual energy x-ray absorptiometry (DEXA) scan has demonstrated no significant osteoporosis in this patient. Superion indirect lumbar decompression would not be considered the standard of care for the enrollee's medical 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 this service have not been met.Therefore, we decided that the Plan does not have to pre-approvethe insertion of a Superion interspinous stabilization device (22869, 22870).
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 this is medically necessary.The Plan denied your request. The Plan says you could be treated at 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 you appear to be improving but require additional short-term acute care services that can safely be completed at the current facility. You do not require any services at the LTACH 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 soon 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-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician visits (81002, 99214, 99203) provided ,, by an out of network (OON) provider.You asked the Plan to pay forthe physician visits. You say that you moved and were not aware you needed a new provider.The Plan denied your request. The Plan says the criteria for OON coverage of the services were not met.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 items/services at issue in this appeal. 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 forthe physician visits (81002, 99214, 99203) provided , by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forlodging provided from September 16, 2020, to October 16, 2020.You asked the Plan to reimburse you forlodging provided after transplant surgery. You say that the Plan should reimburse you for the lodging expense.The Plan denied your request. The Plan says this claim is lacking lodging information needed for processing.The Plan must follow Medicare rules. Medicare rules say that the Plan must provide reasonable accommodations for the enrollee and a companion while in the distant location for medical care.We looked at the file and Medicare rules. You paid for lodging at a family member's home. The Plan guidelines on lodging say rental payments are not covered if renting from a family member or friend or person without a tax ID.You did not have prior authorization for the transplant lodging services. Based on this information, we decided that the Plan's rules for coverage of lodging provided after transplant surgery have not 
been met.Therefore, we decided that the Plan does not have to reimburse you forlodging provided from September 16, 2020, to October 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea referral for an insulin pump and related accessories with an out-of-network provider.You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is a network provider 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 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 Plandoes not haveto pre-approvea referral for an insulin pump and related accessories with an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe wrist x-ray (73110) provided on September 8, 2020.You asked the Plan to pay forthe wrist x-ray. You say that you would like reconsideration because the diagnosis code was appropriate.The Plan denied your request. The Plan says The RT modifier indicated the right side and the diagnosis code S62.601D indicated the left side.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 73110 is not supported in the record. Specifically, the diagnosis code does not match the CPT code billed. The diagnosis code specifies the left index finger while the modifier billed with the CPT code indicates the right side. Based on this information, we decided that Medicare rules for coverage of the wrist x-ray have not been met.Therefore, we decided that the Plan does not have to pay forthe wrist x-ray (73110) provided on September 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe therapeutic continuous glucose monitor (CGM).You asked the Plan to pre-approvethe CGM. You say that you saw an advertisement on television that stated this service would be covered.The Plan denied your request. The Plan says medical necessity criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three dailyinjections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met.Therefore, we decided that the Plan does not have to pre-approvethe therapeutic continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic external defibrillator.

You asked the Plan to pay for an additional unit of automatic external defibrillator, with integrated
electrocardiogram analysis, garment type (K0606). You say that the Plan should pay this claim. The Plan
denied your request. The Plan says the approval was for one unit which was utilized on a previous claim.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units
provided for each procedure code.

We find that only one unit of CPT code K0606 was authorized. One unit was already claimed and paid for.
Based on this information, we decided that Medicare rules for coverage of an additional unit of automatic
external defibrillator, with integrated electrocardiogram analysis, garment type (K0606) have not been met.
Therefore, we decided that the Plan does not have to pay for the automatic external defibrillator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aliqopa (J9057).

You asked the Plan to pre-approve Aliqopa. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is to be used for an off-label and not medically accepted indication.

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 Aliqopa. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found that the requested use of Aliqopa is not FDA-approved for the enrollee's diagnosis and that the use is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aliqopa have not been met. Therefore, we decided that the Plan does not have to pre-approve Aliqopa (J9057).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy guidelines were not followed.

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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no history of osteoporotic fracture. There is no trial and failure of zoledronic acid. The records do not show that zoledronic acid would likely be less effective and/or likely to 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a radiologic examination, chest provided on
November 6, 2020.

You asked the Plan to pay for the radiologic examination, chest. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 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 a radiologic examination, chest provided on November 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says an intensive rehabilitation program is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for COVID pneumonia, respiratory failure, NSTEMI and was discharged home with referral for home health services on March 3, 2021. He continues to have weakness. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider.

You asked the Plan to pay for the office visit. You say that you are resubmitting the claim which supports the billed code being processed for payment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.

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 items/services at issue in this appeal. 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 office visit provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray report provided on August 6, 2020.

You asked the Plan to pay for Radiologic examination, chest; single view (71045). You say that the Plan should pay this claim. The Plan denied your request. The Plan says a modifier was not billed on the claim to represent the services as separate or distinct.

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 Radiologic examination, chest; single view (71045) has a bundled relationship with code Pleural drainage, percutaneous, with insertion of indwelling catheter; with imaging guidance (32557) 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 chest x-ray report provided on August 6, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the admission is not medically necessary.

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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you were admitted to the hospital with difficulty walking after recent spinal surgery. You received oral medications and had stable vital signs. You received physical and occupational therapy in the hospital. You need assistance with functional mobility, including walking 18 feet with a walker. You need varied assistance with activities of daily living. You have no skilled nursing needs. You have skilled therapy needs but do not require skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the remaining dental services.

You asked the Plan to pay for the problem focused exam (D0140), medicament (D1354) or the second and third fillings. You say that because of COVID-19 you could not get an appointment with your dentist for several months. The Plan denied your request. The Plan says contracts exist with individual dentists not facilities.

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 were not provided by an in-network provider. Therefore, we decided that the Plan does not have to pay for the problem focused exam (D0140), medicament (D1354) or the second and third fillings.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the chest x-ray (71045).

You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because this service denied as a duplicate in error. The Plan denied your request. The Plan says that CPT code 71045 is a column II code to a column I code that was billed on the same date of service.

The Plan must follow Medicare rules. Medicare rules say that MACs subject all line items for the same beneficiary, same NPI and same date of service to NCCI edits.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have been met. Specifically, the record indicates that the column I and column II procedures were rendered by different providers. Services rendered by different providers are not subject to NCCI edits. Therefore, we decided that the Plan has to pay for the chest x-ray (71045).

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.