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

We decided that the Plan does not have to pay for outpatient office visit (99204) electrocardiogram (93000) provided on October 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that the enrollee was not a patient of your group at the time your physician's were called to consult but was provided all necessary services and deserve prompt reimbursement of all claims. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 outpatient office visit (99204) electrocardiogram (93000) provided on October 9, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the arthrocentesis provided on December
1, 2020.

You asked the Plan to reduce the copayment for the arthrocentesis. You say that the price is very high for two
relatively inexpensive injections. The Plan denied your request. The Plan says you have been asked to pay the
correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $395
copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital,
including but not limited to hospital or other facility charges and physician or surgical charges.

You have been asked to pay a $395 copayment for the arthrocentesis. The arthrocentesis falls within the
"Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory
Surgical Centers" benefit category. The record shows the arthrocentesis is considered a surgical procedure
performed at an outpatient hospital.

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 reduce the copayment for the arthrocentesis provided on December 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing.

You asked the Plan to pre-approve genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.

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 genetic testing at issue in this appeal is being 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 pre-approve genetic testing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac joint.

You asked the Plan to pre-approve the radiofrequency ablation. You say that you would like reconsideration because this procedure is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of radiofrequency ablation to the sacroiliac joint in the setting of sacroilitis have not been demonstrated in peer-reviewed literature.

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 the radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental because of the wide variation in efficacy in peer-reviewed literature. 

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 radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac joint.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CardioMEMS.

You asked the Plan to pre-approve CardioMEMS. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 CardioMEMS. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of ischemic cardiomyopathy, ejection fraction (EF) equal to 40%. The enrollee is on moderate dose carvedilol and 30 mg twice a day of furosemide but no angiotensin converting enzyme (ACE)/Angiotensin II receptor blockers (ARB) or aldosterone inhibitors. The enrollee has had prior hospital admissions for congestive heart failure (CHF) though none in past several months while adhering carefully to the enrollee's medical and diet regimen per the last physician note from January 2021. The enrollee had no significant symptoms at that January 2021 office visit and no signs on exam of CHF. The enrollee was reported to be NYHA Class II on his most recent cardiology visit (January 2021) and required no medication changes at that time. Based on published studies, expert opinion and FDA indications, CardioMEMS pulmonary pressure device monitoring has been shown to have application in decreasing symptoms and recurrent hospitalizations in patients on fully tolerated guideline directed medical therapy for CHF, who have NYHA Class III symptoms and whose symptoms cannot be well managed using conventional management techniques including physical exam, daily weights, etc. In this clinical situation though, the enrollee is reportedly NYHA Class II at the most recent cardiology visit, with no significant symptoms or signs of CHF and has been stable without recent hospitalizations while adhering carefully to his medical regimen for the past several months. In addition, the enrollee has not been treated with full guideline directed therapy (only moderate doses of beta blocker and loop diuretic only but no ACE/ARB or aldosterone inhibitors). Based on these published indications for Cardiomems device insertion, the enrollee would therefore not meet the medical necessity criteria for the requested 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not have to pre-approve CardioMEMS.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant
(D6010) and surgical access to an implant body (D6011).

You asked the Plan to pre-approve the endosteal implant. You say that you have no fixed teeth and it would be
much more convenient to have implants. The Plan denied your request. The Plan says the services are not
covered under your dental benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
surgical placement of implant body: endosteal implant (D6010) and surgical access to an implant body
(D6011).
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for 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 you did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, you did not require any skilled services on an inpatient basis, at a SNF level of care as of April 22, 2021. 

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. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.

You asked the Plan to pre-approve acute inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the procedure is currently approved as an ambulatory procedure.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary for the enrollee in this case. The enrollee is undergoing a planned total hip arthroplasty. The enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under CPT code 27130 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. Our physician reviewer found that the enrollee's condition does not meet criteria for inpatient hospital 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 acute inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a platelet rich plasma injection.

You asked the Plan to pre-approve the platelet rich plasma injection. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says this service is considered experimental at this time for the treatment of the member's condition.

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 the platelet rich plasma injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this service for elbow pain remains experimental and more research is needed to show its safety and efficacy. 

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 platelet rich plasma injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a platelet rich plasma injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.

You asked the Plan to pre-approve the compression stockings. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested items are not medically
necessary.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are
noncovered 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 A6549.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 25 home health physical therapy visits.

You asked the Plan to pre-approve the 25 physical therapy visits. You say that you would like reconsideration
because the requested physical therapy is medically necessary. The Plan denied your request. The Plan says the
clinical documentation does not show that the unique skills of a physical therapist are required to restore or
maintain function or to prevent deterioration.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.

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 25 physical therapy visits. Our
reviewer says that further skilled therapy at this point does not appear to be likely to achieve any significant
improvement in the member's symptoms or functional status. Further utilization of the home exercise program
appears appropriate at this point. Our physician reviewer found based on the medical records provided there is
no documentation that the unique skills of a professional therapist are required to safely and effectively provide
treatment, that the services can be safely and effectively performed only by a therapist or under the supervision
of a therapist.

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 25 physical therapy visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve 25 home health physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supart FX.
You asked the Plan to pre-approve Supart FX. You say that this is medically necessary. The Plan denied your request. The Plan says that you have not tried and failed Monovisc.
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 Supart FX. Our reviewer says that Supartz FX is not medically reasonable and necessary in this case. You have not tried and failed Monovisc. There is no documentation provided indicating that Monovisc would likely be less effective and/or likely have adverse effects for you. Our physician reviewer found that your condition does not meet step therapy criteria for Supartz FX. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supart FX have not been met. Therefore, we decided that the Plan does not have to pre-approve Supart FX.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the broken bone occurred more than twelve weeks ago.
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 the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the records do not show an acute spine fracture that is less than six weeks old. The criteria have not been
met.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve percutaneous vertebral augmentation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neulasta Onpro (CPT code J2505), for the enrollee.

You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied
your request. The Plan says the enrollee is in a clinical trial; therefore, coverage for the services is through
Medicare and not the enrollee's health plan.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the medication have not been met. The information we have says
the enrollee is in a clinical trial. The Centers for Medicare and Medicaid Services (CMS) National Coverage
Determination (NCD) titled Routine Costs in Clinical Trials (310.1) states Medicare Advantage plans such as
the enrollee's health plan cannot require pre-approval for services related to clinical trials. Therefore, the
requested services will not be reviewed for authorization. The Medicare Claims Processing Manual, Chapter
32, Section 69.9 also says that claim payment for managed care plan members for the covered routine costs
associated with a clinical trial is the responsibility of the original Medicare contractor, and not the managed
care plan. The claims for routine costs associated with this clinical trial are not payable by the enrollee's health
plan. The enrollee's provider should submit claims to the Original Medicare contractor for the enrollee's state
which can be located by searching on the CMS website at http://cms.hhs.gov. Therefore, we decided that the
Plan does not have to pre-approve Neulasta Onpro (CPT code J2505), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve One Touch Verio glucose test strips.

You asked the Plan to pre-approve One Touch Verio glucose test strips. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested items.

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. Based on this information, we decided that Medicare rules for coverage of One Touch Verio glucose test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve One Touch Verio glucose test strips.