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

We decided that the Plan does not have to pre-approve transthoracic echocardiography (93306).

You asked the Plan to pre-approve transthoracic echocardiography. You say that the medical records provided should support the medical necessity of the requested service. The Plan denied your request. The Plan says the records do not support that repeated testing is 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 transthoracic echocardiography. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found prior ECHO from 2020 showed EF 81%. The enrollee is asymptomatic, without new signs or symptoms. There was no justification made in recent documentation to repeat this test without symptoms that might change the results. There was no planned procedure or other indication for this test. Therefore, this request will be considered 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 transthoracic echocardiography have not been met. Therefore, we decided that the Plan does not have to pre-approve transthoracic echocardiography (93306).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5211) and a partial lower denture (D5212).

You asked the Plan to pre-approve the dental services. You say that the partial dentures should be covered. The Plan denied your request. The Plan says dentures are covered once every 60 months. The Plan also says that the frequency limit has been reached.

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 and partial dentures are listed as covered, the frequency limit has been reached. The record shows that the Plan paid for partial dentures that you
received on February 20, 2020. Therefore, we decided that the Plan does not have to pre-approve a partial
upper denture (D5211) and a partial lower denture (D5212).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for neurophysiological monitoring (95938, 95955) provided on March 2, 2020.

You asked the Plan to pay for neurophysiological monitoring. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that if a mobile unit is serving an entity for which another POS code already exists, providers should use the POS code for that entity.

We looked at the file and Medicare rules. The services at issue were billed with the mobile unit POS 15, but the records show that these services were provided serving an entity for which another POS code already exists.

Based on this information, we decided that Medicare rules for coverage of neurophysiological monitoring have not been met. Therefore, we decided that the Plan does not have to pay for neurophysiological monitoring (95938, 95955) provided on March 2, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on August 21, 2020.

You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior 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 physical therapy services. 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 physical therapy services provided on
August 21, 2020.
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 with supporting records. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says this medication is being given by the provider or supervised by provider, but the drug is not being supplied by the provider. The Plan also says that this medication does not fall under Part B.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia.

Benefits for Prolia may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit with an out-of-network urologist.

You asked the Plan to pre-approve the out-of-network office visit. You say that your primary care physician
required you to follow up with this doctor and you cannot wait any longer. The Plan denied your request. The
Plan says you must receive your care from 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
the office visit with an out-of-network urologist.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ambien tablets (J8499).

You asked the Plan to pre-approve Ambien. You say that the enrollee has a medical need for Ambien. The Plan denied your request. The Plan says this medication does not fall under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ambien tablets (J8499).

Benefits for Ambien may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the OON physical therapy services. You say that The Plan denied your request. The Plan says there are in-network providers where the enrollee can receive the physical therapy services needed.

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 physical therapy to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on November 3, 2020.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. 

We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not include definitive laboratory results for 22 or more drug classes to support the coding criteria for this code. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on November 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor system.

You asked the Plan to provide a therapeutic continuous glucose monitor system. You say that due to the enrollee's medical condition using a conventional blood glucose meter is difficult. The Plan denied your request. The Plan says criteria for a CGM is not 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 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 a therapeutic continuous glucose monitor system have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitor system.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for outpatient rehabilitation services provided on January 5, 2021, to March 23, 2021.

You asked the Plan to waive the co-payment for outpatient rehabilitation services. You say that you were never told there would be a co-payment per each visit. You also say that you did not have to pay out of pocket for 2020. The Plan denied your request. The Plan says the co-payment you are being charged is correct.

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 $35 co-payment for each outpatient rehabilitation service.

You have been asked to pay a $35 co-payment for outpatient rehabilitation services. The total amount owed on this claim is $595 ($35 x 17 visits = $595). The EOC confirms that $35 is the required co-payment for this service. 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 outpatient rehabilitation services (97110, 97112, 97140, G0283, 97150) provided on January 5, 2021, to March 23, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lupron.

You asked the Plan to pre-approve Lupron. You say that Lupron is a reasonable course of treatment. The Plan denied your request. The Plan says the enrollee has not tried and failed Eligard and Firmagon.

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 Lupron. Our physician reviewer found that the enrollee has advanced prostate cancer. The Plan requires a trial of Eligard and Firmagon before they will approve the requested drug. The provided records did not clearly show that the enrollee has tried and failed either Eligard or Firmagon. The plans required drugs are not likely to be less effective or have more adverse effects for the enrollee's 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 Lupron have not been met. Therefore, we decided that the Plan does not have to pre-approve Lupron.
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 you need IRF care. The Plan denied your request. The Plan says rules for IRF care 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 you were admitted to an acute care hospital for altered mental status, sepsis and a urinary tract infection. 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. Although you do require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. In conclusion, 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. 

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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home assistance with activities of daily living.

You asked the Plan to pre-approve the requested services. You say that you cannot bathe yourself or walk. The Plan denied your request. The Plan says the services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered.

We looked at the file and Medicare rules. The case file does not show that you require skilled nursing or therapy services. Custodial care is not covered. Based on this information, we decided that Medicare rules for coverage Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve home assistance with activities of daily living.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided on September 23, 2020.

You asked the Plan to pay for a neuromuscular stimulator. You say that this should be covered. The Plan denied your request. The Plan says there is not a valid proof of delivery for this item.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid proof of delivery for the supplies provided in this case. The proof of delivery shows a delivery date of March 12, 2020, but the item at issue was billed with a date of service of September 23, 2020. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided on September 23, 2020.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pre-approve transcranial magnetic stimulation.

You asked the Plan to pre-approve the requested services. You say that the enrollee continues to experience poor drug response and consistent worsening clinical manifestations. The Plan denied your request. The Plan says that the enrollee does not have a confirmed diagnosis of severe depression.

The Plan follows Medicare rules. Medicare rules say that transcranial magnetic stimulation is only covered under certain medical indications.

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 requested services. Our physician reviewer found that the enrollee has been depressed on and off for decades but persistently for the last 2 years. The trigger seems to be the death of his friend and the patient has been unable to play tennis due to physical concerns. He does meet the clinical criteria having taken Paxil, Zoloft, Lexapro, Luvox, Prozac, Effexor, Pristiq and Cymbalta, Remeron, Wellbutrin, Elavil, Trintellix, Lamictal, Depakote and Ritalin with no effect or side effect. The note from both April and July say the enrollee has recurrent depression, severe.

Based on the information provided, the enrollee does have an indication for the requested Transcranial Magnetic Stimulation (TMS). It does meet the coverage criteria based on the history and testing for Transcranial Magnetic Stimulation (TMS) in the treatment of Major Depressive Disorder.

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 requested services have been met. Therefore, we decided that the Plan has to pre-approve transcranial magnetic stimulation.

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 pay for the moderate sedation services rendered on May 28, 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 professional component (PC)/technical component (TC) indicator of 3 represents TC only codes. 

We looked at the file and Medicare rules. Billed procedure code 99153 (moderate sedation services) has a PC/TC indicator of 3 and no separate PC payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered on May 28, 2020.