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

We decided that the Plan does not have to pay for a sleep study provided on January 11, 2021 by an out of network (OON) provider.
You asked the Plan to pay for a sleep study. You say that you would like this claim reprocessed and paid due to medically necessity. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 a sleep study provided on January 11, 2021 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right knee surgery.

You asked the Plan to pre-approve right knee surgery. You say that the requested right knee surgery is medically necessary. The Plan denied your request. The Plan says the requested right knee surgery 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 right knee surgery. Our reviewer says that the requested right knee surgery is not medically necessary. Our physician reviewer found the medical records show that the enrollee has knee arthritis and a degenerative meniscal tear. The surgery is for debridement. The medical literature does not show a significant benefit to knee arthroscopy debridement in geriatric patients. It is not medically needed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of right knee surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve right knee surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PILD.

You asked the Plan to pre-approve PILD. You say that you would like reconsideration because this service is covered and medically necessary. The Plan denied your request. The Plan says the requested procedure is a benefit exclusion under Medicare by the terms of the NCD.

The Plan must follow Medicare rules. Medicare rules say that PILD for Lumbar spinal stenosis may only be covered under the context of a clinical trial 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PILD have not been met. Specifically, the record does not clearly indicate that the member is enrolled in one of the Medicare approved clinical trials. Therefore, we decided that the Plan does not have to pre-approve PILD.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the diagnostic colonoscopy provided on December 8, 2020.

You asked the Plan to waive the co-payment for the colonoscopy. You say that the colonoscopy performed was a screening for colorectal cancer and should not be subject to co-payments. You say that the claim should be reprocessed and covered in full. The Plan denied your request. The Plan says the co-payment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 co-payment for each Medicare-covered outpatient hospital service.

You have been asked to pay a $250 co-payment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show the colonoscopy was ordered due to a positive Cologuard test, which is considered a diagnostic colonoscopy. 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 co-payment for the diagnostic colonoscopy provided on December 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections (J0585).

You asked the Plan to pre-approve Botox injections. You say that studies have shown this is effective for pelvic floor spasms. The Plan denied your request. The Plan says this is not covered the enrollee's condition.

The Plan must follow Medicare rules. Medicare rules say that OnabotulinumtoxinA is indicated for the treatment of overactive bladder (OAB) with symptoms of urge urinary incontinence, urgency, and frequency, in adults and patients five years of age and older who have an inadequate response to or are intolerant of an anticholinergic medication. Payment will not be made for Botox for any spastic condition of smooth muscle, such as spastic colon and biliary dyskinesia, or of any spastic condition not listed under "ICD-10-CM Codes That Support Medical Necessity" in Article A52848. Pelvic Floor Muscle Spasms are not listed as supporting medical necessity. 

We looked at the file and Medicare rules. The record does not show that the enrollee's urinary incontinence cannot be treated with an anticholinergic medication, and Botox is not covered for pelvic floor muscle spasms. Based on this information, we decided that Medicare rules for coverage of Botox injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox injections (J0585).
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 service is medically necessary and reasonable. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.

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 the patient appears to be receiving an appropriate level of care in the present setting and the acute inpatient rehabilitation facility appears to be able to provide for all of the patient's present inpatient care needs. 

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. Specifically, this patient does not require the services on an inpatient basis, only in a skilled nursing facility setting. Medically necessary services are available at the enrollee's current level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 26, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as 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.
In this case, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says that the requested device is being used in the bilevel PAP mode rather than being used as a home ventilator.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 home ventilator. Our reviewer says that a home ventilator is not medically reasonable and necessary in this case. You are status post May 6  hospital admission with acute hypoxic respiratory failure. Partial pressure of carbon dioxide on arterial blood gases has been found to be 54.2. The order for the ventilator with noninvasive interface for a AVAPS setting. You have been prescribed BiPAP as a nocturnal respiratory assist device. There is no evidence that the requested mechanical ventilator is indicated. Our physician reviewer found that your condition does not meet Medicare criteria for a home ventilator. 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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
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 these services are medically necessary. The Plan denied your request. The Plan says that you are unlikely to tolerate 3 hours of intensive therapy daily with at least 15 hours of intensive rehabilitation within a 7 consecutive day period.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for chemotherapy induced
neutropenia, sepsis, acute kidney injury and diarrhea. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on
November 25, 2020, November 30, 2020, and December 21, 2020.
You asked the Plan to pay for the home visits. You say that the doctor was not responsible to get authorization
since the member was in a nursing facility. You say that the claim should be reprocessed, and the provider
reimbursed for services rendered. The Plan denied your request. The Plan says this provider is an out-ofnetwork
provider and did not obtain authorization.
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 home visit provided by an out-of-network
provider on November 25, 2020, November 30, 2020, and December 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you have ruled out the use of a basic pump. The enrollee had a trial with an E0651 device that resulted in increased swelling. A trial with Flexitouch was much more successful. The Plan denied your request. The Plan says the records support that the enrollee meets the Medicare criteria for the requested device.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee has lymphedema extending onto the chest, trunk and/or abdomen or has had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.

You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this request is medically necessary.The Plan denied your request. The Plan says the criteria for coverage have 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 daily injections, 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 you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic shoes to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve diabetic shoes. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items can be provided by a network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve diabetic shoes to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a pontic (D6241) for tooth #3, #5 and #11, and a retainer crown (D6751) for tooth #2, #4, #6, #10 and #12.

You asked the Plan to pre-approve the bridgework. You say that these services are necessary. The Plan denied your request. The Plan says that they have agreed to cover one pontic and one retainer crown, however the others requested exceed the benefit allowance for these procedures.

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 said they would cover one pontic and one retainer crown. The specific teeth for which these procedures were approved was not specified. The others were denied as exceeding the Plan's benefit limit for these services for the next 60 months. However, the Plan's Office Reference Manual clearly states that each of these procedures may be covered once every 60 months per tooth, which means that each tooth is eligible for these procedures once within a 60-month period.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the bridgework have been met. Therefore, we decided that the Plan has to pre-approve a pontic (D6241) for tooth #3, #5 and #11, and a retainer crown (D6751) for tooth #2, #4, #6, #10 and #12.

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 specialist services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve specialist services. You say that you would like approval for these services to be provided by an out-of-network provider. The Plan denied your request. The Plan says there are in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.