Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the initial hospital care (99223) provided on November 28, 2020
You asked the Plan to pay for the initial hospital care. You say that you would like reconsideration because this
physician rendered medically necessary services under plan directed care in good faith. The Plan denied your
request. The Plan says that CPT code 99223 was reported with a critical care evaluation and management
service on the same date of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The
rules also say that when critical care services are provided on a date where an inpatient hospital or
office/outpatient evaluation and management service was furnished earlier on the same date at which time the
patient did not require critical care, both the critical care and the previous evaluation and management service
may be paid.
We find that CPT code 99223 is supported in the record. Specifically, the record indicates that the member was
not in the intensive care unit when this physician rendered services. This service is separately reimbursable.
Based on this information, we decided that Medicare rules for coverage of the initial hospital care have been
met. Therefore, we decided that the Plan has to pay for the initial hospital care (99223) provided on November
28, 2020
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: Hospice
Decision: Unfavorable

We decided the Plan does not have to pay for services provided under code 11043.

You asked the Plan to pay for code 11043. You say that this claim should be paid. The Plan denied your request. The Plan says the denial for code 11043 will be upheld as the enrollee was registered or enrolled in a Federal Hospice Program and the claim should have been billed to Original Medicare. The Plan states code A6213-A1 will be sent to the claims department for reprocessing. The Plan states this claim should billed to Original Medicare first for payment.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for services provided to the enrollee and billed under code 11043.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One (J7326).
You asked the Plan to pre-approve Gel-One (J7326). You say that you want the enrollee to be treated with this
drug. The Plan denied your request. The Plan says the health plan states the enrollee has not first tried and had
a contraindication or intolerance to Orthovisc and 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 Gel-One (J7326). Our reviewer says
that the drug is not medically necessary. Our physician reviewer found based on the medical records provided
the patient has not tried and failed the required drugs. Based on the medical records provided there is no
indication that the plan's required drugs 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 Gel-One (J7326) have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One (J7326).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the deluxe frames (V2025) and progressive lenses (V2781).

You asked the Plan to pay for the eyeglasses. You say that you were given conflicting information about whether the provider was covered under the Plan's network. The Plan denied your request. The Plan says you received eyewear from a provider who is not part of the third-party vendor's Select network and therefore it is not covered.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when you use one of the vision vendor's "Select" provider for routine coverage including eyewear allowance.

We looked at the file and the Plan's rules. The Plan does not cover eyewear provided by an out-of-network provider. We verified that the vision provider who furnished your eyewear is not part of the their-party vision vendor's "Select provider network. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the deluxe frames (V2025) and progressive lenses (V2781).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating
provider on February 25, 2020, to March 30, 2020.
You asked the Plan to waive the copayment for lab work. You say that you had a printout that showed your
expected cost to be $0. The Plan denied your request. The Plan says the correct copay has been applied.
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 $10
copayment for outpatient diagnostic tests/lab services.
You have been asked to pay a $10 copayment for lab work. The total amount you are being asked to pay is $20
($10 x 2 = $20). Lab work falls within the outpatient diagnostic tests/lab services benefit category. 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 copayment for lab work provided by a participating provider on February 25, 2020,
to March 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea 2mg/0.05ml 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 there is no indication of therapeutic failure or intolerance after a trial with one plan-preferred medication.

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, the enrollee has not tried and failed Avastin. There is no indication that the plan's required drug would likely be less effective and/or likely 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 Eylea 2mg/0.05ml for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a 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 medical needs are being met at the current 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 review indicates that the enrollee
does not require services at the LTACH that are not available at the acute care hospital where he 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 LTACH for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the dialysis catheter circuit procedure provided by an out of network (OON) provider.

You asked the Plan to pay for the dialysis catheter circuit procedure. You say that you were unable to obtain authorization because the enrollee was an add-on for that day. The Plan denied your request. The Plan says no prior authorization was obtained.

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 dialysis catheter circuit procedure provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a continuous glucose monitor and supplies.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that medical necessity was not established.

The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically necessary.

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 considered medically reasonable and necessary in this case. Our physician reviewer found you are on a sliding scale, and have been advised to check your levels four times a day. This implies that you are taking insulin at meals, which would qualify you for this monitor. Your living situation makes this request particularly beneficial and useful, since it would be hard for someone to take the sensor which is adherent to your skin (as opposed to the glucometer, which was taken from you).

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 been met. Therefore, we decided that the Plan has to pre-approve a continuous glucose monitor and supplies.

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 psychiatry services provided on December 9, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for psychiatry services. You say that authorizations are not going through for these
visits for psychiatry and you are being charged for every visit. The Plan denied your request. The Plan says
prior authorization was not obtained by the member's primary care physician. The Plan says that there are innetwork 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 psychiatry services provided on December 9, 2020
by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya.

You asked the Plan to pre-approve Ilumya. You say that this treatment is medically appropriate and necessary. The Plan denied your request. The Plan says the enrollee is not already using Ilumya. The Plan says that there is no evidence that the preferred drugs would be contraindicated. The Plan also says that this request does not meet the Plan's Part B step therapy criteria for Ilumya.

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 Ilumya. Our reviewer says that Ilumya is not medically necessary. Our physician reviewer found based on the medical records provided the enrollee has not tried and failed the required drug. The reviewer also found that the provided medical records show no indication that the Plan's required drugs would likely be less effective and/or likely 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.

You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has spinal stenosis. The requested Vertiflex Superion spacer is considered experimental in nature, as more research is needed to show efficacy. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the laparoscopy services coded 49650.

You asked the Plan to pay for the laparoscopy services. 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 payable.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.

this case, the MUE for CPT code 49650 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the laparoscopy services have not been met. Therefore, we decided that the Plan does not have to pay for the laparoscopy services coded 49650.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) and an expandable controller (E2377) with expandable harness (E2313) and electronic connection (E2311) for a Group 3 power wheelchair.

You asked the Plan to pre-approve a power seat elevation feature and an expandable controller with expandable harness and electronic connection. You say that the request is for continuity of care. The Plan denied your request. The Plan says the requested items 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. Medicare rules also say that a power seat elevation feature is non-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 a power seat elevation feature and an expandable controller with expandable harness and electronic connection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has polio, hyperlipidemia, obstructive sleep apnea, hypertension, lymphedema, degenerative joint disease, chronic back pain, and post-polio syndrome. The documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength in the upper extremities supports that the enrollee should able to control any power options through their own individual switches.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller with expandable harness and electronic connection have not been met. A power seat elevation feature is non-covered. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) and an expandable controller (E2377) with expandable harness (E2313) and electronic connection (E2311) for a Group 3 power wheelchair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim processed correctly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

We looked at the file and the rules. The file shows that the claim was not billed with valid diagnosis codes. A corrected claim was not provided. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar-sacral orthosis and an addition to Thoracic-Lumbar-Sacral Orthosis to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve a lumbar-sacral orthosis and an addition to Thoracic-Lumbar-Sacral Orthosis. 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 a lumbar-sacral orthosis and an addition to Thoracic-Lumbar-Sacral Orthosis to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee currently meets LTACH criteria. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.

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 the enrollee is receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that are not available at the acute care hospital where he is currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 

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 long term acute care hospital (LTACH) services.