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

We decided that the Plan does not have to pre-approve Entyvio (J3380).

You asked the Plan to pre-approve Entyvio (J3380). You say that you want the enrollee treated with this drug. The Plan denied your request. The Plan says the enrollee has not first tried and failed Remicade or Inflectra, and Stelara.

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 Entyvio (J3380). Our reviewer says that based on the medical records provided the patient has not tried and failed the required drug(s). Our physician reviewer found based on the medical records provided there is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the patient. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio (J3380) have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio (J3380).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an office visit.

You asked the Plan to pre-approve the office visit. You say that the enrollee would prefer to continue to see this provider, especially during the current pandemic. The Plan denied your request. The Plan says that the provider is out-of-network.

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. The Plan did not provide the 2021 Evidence of Coverage. The plan has not shown that a lock-in rule exists in this contract. This means we are unable to make a determine if there are lock-in rules. Therefore, we decided that the Plan has to pre-approve the office visit.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH)
for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says care can be provided in the current inpatient hospital.

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 there is no documentation provided necessitating admission to a LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis.

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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6534.

You asked the Plan to pre-approve the compression stockings. You say that you need the compression stockings to control the pain and swelling in your legs so that you can walk. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6534 are non-covered because they do not meet the statutory definition of a surgical dressing.

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6534.
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 November 12, 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 November 12, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that you are not able to care for yourself at home any longer. The Plan denied your request. The Plan says the records do not show the enrollee has daily skilled nursing or therapy needs that can only be provided on an inpatient basis in a SNF.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. He is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee does not have any parental medication, complex wound care or nutrition given via a feeding tube. He is medically stable without any acute exacerbations of chronic medical problems. His physical function is at or near his baseline and he can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 14, 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 the testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.

The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to pay for the laboratory services rendered on October 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection between two or more power seating system motors.

You asked the Plan to pre-approve an electronic connection between two or more power seating system motors. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that an electronic connection between two or more power seating system motors is only covered for certain indications.

We looked at the file and Medicare rules. Review of the file shows that the enrollee has adequate power strength to control the power options using their own switches which are included in the allowance of these power options. The documentation does not support a medical need to control the power options through the joystick. Based on this information, we decided that Medicare rules for coverage of an electronic connection between two or more power seating system motors have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection between two or more power seating system motors.
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 the Medicare criteria for an IRF admission have not been met.
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 based on the documentation provided, the health Plan's denial should be upheld. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care (ex. skilled nursing facility/sub-acute rehab).
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that without admission to a LTACH, the enrollee will not be able to function. The Plan denied your request. The Plan says based on Medicare guidelines, the LTACH services you and your provider are requesting do not meet the requirements for approval.

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 that the enrollee was admitted to the current acute care hospital with acute respiratory failure, COPD exacerbation treated with steroids, oxygen, BiPAP, and antibiotics. He was also treated for atrial fibrillation and later switched to oral medication. Recent notes describe the enrollee having improved respiratory status, approaching his baseline, and tolerating the Life 2000 ventilator support device in preparation for use of this device at home. The enrollee appears to be improving and only requires short term acute care services which can be safely completed at the current facility. The enrollee does not require services at the LTACH that are not already available and covered 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-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for the dental cleaning (D1110) and periodic oral evaluation (D0120) provided on January 14, 2021.

You asked the Plan to waive the cost-share for the cleaning and evaluation. You say that you were told that you had a $0 copay when you use a network dentist and feel you should be reimbursed the full amount for the services provided. The Plan denied your request. The Plan says you used an out-of-network provider and these charges were 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 $0 co-payment for a cleaning and a routine periodic exam. For services obtained out-of-network, the Plan only pays up to a certain amount. If you choose to see an out-of-network dentist you might be billed for any amount greater than what the Plan pays, even for services listed as a $0 co-payment.

You have been asked to pay $0 for the evaluation. The provider billed $19 for the evaluation, and the Plan's maximum allowed charge for this service is $19. The Plan paid the full allowed $19 for this service, leaving you with $0 responsibility for the evaluation. This means that you have been asked to pay the correct amount for the evaluation based on your contract with the Plan.

You have been asked to pay $56 for the cleaning. The Plan's maximum allowed charge for this service is $44. This is the rate that in-network providers have agreed to be paid, but out-of-network providers do not have this agreement. The Plan paid the full $44 allowed amount for this service, leaving you with a $0 co-payment on the Plan's allowed cost for a dental cleaning. However, if you choose to see an out-of-network dentist you may be billed for any amount greater than what the Plan pays. The out-of-network provider billed $100 for the cleaning, so you are responsible for the difference between this bill and the Plan's allowed payment. ($100 - $44 = $56). This means that you have been asked to pay the correct amount for the cleaning 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 cost-share for the dental cleaning (D1110) and periodic oral evaluation (D0120) provided on January 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).

You asked the Plan to pre-approve therapeutic CGM. You say that you are appealing this denial. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for a therapeutic CGM.

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 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 therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder sling provided on September 20, 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 the services are not covered.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. We looked at the file and Medicare rules. The services at issue are described by procedure code A4566. This code has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the shoulder sling provided on September 20, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued SNF care. You say that the enrollee is still recovering and is
relearning basic life skills. You say that the enrollee was independent before going into the facility. The Plan
denied your request. The Plan says the enrollee does not meet the criteria for continued admission to a SNF.
The Plan says that the enrollee no longer requires daily skilled services.
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 continued SNF care. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found at the time of admission, the
enrollee required skilled rehab services to improve function due to weakness and deconditioning. There were
no skilled nursing needs. As of May 28, 2021, the enrollee did not require any skilled nursing or rehab services
on a daily basis. She was not expected to make measurable gains within a reasonable and predictable period of
time or require skilled therapy to prevent deterioration with mobility or activities of daily living. The enrollee
did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the
enrollee did not require any skilled services on an inpatient basis, at a SNF level of care as of May 28, 2021.
She did not have any parental medications, complex wound care or nutrition given via a feeding tube. The
enrollee received skilled care and improved; however, her function had plateaued by May 28, 2021, and she did
not require any further inpatient skilled rehab services. The enrollee's function was at or near her prior level of
function and she could be discharged to a lower level of care for further services. As of May 28, 2021, the
enrollee required custodial services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan
does not have to pre-approve continued skilled nursing facility (SNF) services.