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

We decided that the Plan does not have to pre-approve Aranesp for the enrollee.
You asked the Plan to pre-approve Aranesp. You say that this is medically necessary. The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception.
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 Aranesp. Our reviewer says that Aranesp is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed Retacrit or that it would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Aranesp. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on July 26, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0648). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number, the Proof of Delivery did not include details to corroborate the Delivery Ticket, and the physician order does not include a description or HCPC code for the orthosis.
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 shows that the Plan made several attempts to obtain the valid physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order or proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it, the Proof of Delivery does not have a description of the items delivered and the physician order does not have a description or code of the supply billed. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on July 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the requested shower chair is needed so you can safely and correctly bathe yourself. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveproton beam radiation treatment (77525).You asked the Plan to pre-approveproton beam radiation treatment. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that proton beam therapy will be considered medically reasonable and necessary for specific conditions.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 proton beam radiation treatment. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no definitive data to suggest that protons are superior to photonintensity-modulated radiation therapy (IMRT) for prostate cancer. IMRT remains the standard of care and is the recommended treatment. The requested treatment does not meet medical necessity criteria.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam radiation treatment have not been met.Therefore, we decided that the Plan does not have to pre-approve proton beam radiation treatment (77525).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not have to pre-approveplatelet rich plasma injections (0232T).You asked the Planto pre-approveplatelet rich plasma injections. You say that this should be covered.The Plandenied your request. The Plansays this service is not medically necessary.The Plan follows Medicare rules. Medicare rules say that platelet rich plasma injections represented by CPT code 0232T are considered not medically necessary.We looked at the file and Medicare rules. The requested service is considered not medically necessary. Based on this information, the rules for coverage of platelet rich plasma injections have not been met. Therefore, we decided that the Plan does not have to pre-approveplatelet rich plasma injections (0232T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea knee orthotic (L1851).You asked the Plan to pre-approvea knee orthotic (L1851). You say that the requested knee orthotic is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested knee orthotic.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 a knee orthotic (L1851). Our reviewer says that the enrollee does not meet criteria for the requested knee orthotic. Our physician reviewer found the enrollee is with arthritis of the right knee with knee pain. The medically necessity of a right knee orthotic is in question. Based on the medical records provided the enrollee does not have a covered indication for the requested knee orthotic (L1851) under LCD L33318.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a knee orthotic (L1851) have not been met.Therefore, we decided that the Plan does not have to pre-approvea knee orthotic (L1851).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve authorization to have a tracheostomy completed for the member at home.You asked the Plan to pre-approve the authorization for the tracheostomy in the member's home. You say that the tracheostomy tube has to be changed by a qualified medical specialist and it is not safe and too harrowing for the member to travel. The Plan denied your request. The Plan says that due to the clinical nature associated with the change of a tracheostomy, and safety concerns involved with the procedure, member should come into the medical facility to have the tracheotomy change completed.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the authorization for the tracheostomy in the member's home. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the procedure has been stated to be able to be done by a family member and an unreasonable degree of morbidity is taken upon patient to go to the hospital. If it is at all feasible to perform this procedure in the home environment, this would be an indication given the medical and environmental circumstances.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 authorization for the tracheostomy in the member's home have been met. Therefore, we decided that the Plan has to pre-approve authorization to have a tracheostomy completed for the member at home. 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 a prolonged service in an inpatient or observation setting (99356) provided on August 5, 2019.You asked the Plan to pay for the prolonged hospital service. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the billed service.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 99356 is prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient Evaluation and Management service).We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the prolonged hospital service. Our reviewer says that the billing of CPT 99356 is not supported.Our reviewer found the documentation does not support that a prolonged amount of time, beyond that which would normally be provided to such a patient, was provided. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the prolonged hospital service have not been met. Therefore, we decided that the Plan does not have to pay for a prolonged service in an inpatient or observation setting (99356) provided on August 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean implant supported crown (D6066).You asked the Plan to pre-approvethe dental service. You say that the enrollee was approved for implant surgery # 3. You also say that this is a continuous implant procedure.The Plan denied your request. The Plan says implant supported crowns are not a covered service.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, an implant support crown is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvean implant supported crown (D6066).
Appeal type: Other
Decision: Unfavorable

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You can find this information on page 76 of the Plan's 2020 EOC.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTrelegy Ellipta for the enrollee.You asked the Plan to pre-approvethis drug. The Plan denied your request. The Plan says that this is not covered under the member's plan under any normal circumstances.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-approveTrelegy Ellipta for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positron emission tomography (PET) and computed tomography (CT) services.

You asked the Plan to pre-approve the PET/CT services. You say that a bone marrow biopsy was taken and that the requested service is needed so that the facility can know how to move on. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of a PET scan at this time, since there is not a confirmed diagnosis of cancer after multiple testing has been performed.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when 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 PET/CT services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has monoclonal protein and weight loss. Our physician reviewer found that there has been no diagnosis of myeloma made yet. Our physician reviewer found that marrow needs to be done and, only then, along with a myeloma diagnosis, would the PET/CT be indicated.

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 PET/CT services have not been met. Therefore, we decided that the Plan does not have to pre-approve positron emission tomography (PET) and computed tomography (CT) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the operating room service provided on August 26, 2019.You asked the Plan to waive the copayment forthe operating room service. You say that you were never told the copayment would be $150. The Plan denied your request. The Plan says you have been charged 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 $150 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center of hospital outpatient facility. You have been asked to pay a $150 copayment for the operating room service. The operating room service falls within "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 the operating room service provided on August 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home delivered meals.
You asked the Plan to pre-approve Nutri System home delivered meals. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Nutri System home delivered meals are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Nutri System home delivered meals are not considered medically reasonable or necessary. Based on this information, we decided that Medicare rules for coverage of home delivered meals have not been met. Therefore, we decided that the Plan does not have to pre-approve home delivered meals.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation therapy (36482).You asked the Plan to pre-approve endovenous ablation therapy. Yousay that the enrollee's condition is refractory to conservative therapy.The Plan denied your request. The Plan says the enrollee has not had 3 months of conservative therapy.The Plan follows Medicare rules. Medicare rules say that  vein stripping and/or sclerotherapy is covered when the above listed indications are present.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rulesto determine if the Plan was correct in denying the request to pre-approve endovenous ablation therapy. Our reviewer says that coverage criteria have not been met. Our physician reviewer found there is no documentation that the patient's pain is lifestylelimiting. There is no documentation of any effort at conservative treatments initiated by the treating provider. There does not appear to be any evidence that the patient's intolerance to compression stockings was investigated or efforts made to provide aconservative regimen that could be tolerated. There is documentation that peripheral pulses are abnormal. This patient has numerous cardiovascular risk factors. Without objective evidence, the absence of significant peripheral artery disease has not yet been demonstrated. There is absence of greater saphenous vein dilatation and the reflux times are modest and out of proportion to severe leg pain.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of endovenous ablation therapy have not been met.Therefore, we decided that the Plan does not have to pre-approveendovenous ablation therapy (36482)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says theLTACH admission is not medically necessary as the member is receiving appropriate in-patient acute careand does not require transfer to a longterm acute care hospital.The Plan must follow Medicare rules. The rules say that LTACH services are coveredif 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 enrollee does not meet criteria for coverage of a LTACH admission. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, 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-approvelong term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve the extraction of roots with bone (CPT D7250) for tooth #30.
You asked the Plan to pre-approve the extraction of roots with bone for tooth #30. You say that your pain is at a level of 8-10 in your jaw from the bone that's still in there. You say that you have endured this pain for over 8 months while waiting for the referral process to move alone. You say that the pain is extremely uncomfortable, is limiting your food intake, and is creating mental anguish. The Plan denied your request. The Plan says that the documentation does not support that the requested code is required. The Plan says that a less severe extraction code would be considered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers extractions when the services are medically necessary and reasonable. 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 extraction of roots with bone for tooth #30. Our reviewer says that the requested extraction is medically reasonable and necessary. Our physician reviewer found there are residual roots embedded in the bone in the area of tooth #30. The residual root is submerged and apparently covered by bone and would require removal of bone to extract the remaining root. This appears to be a residual root and not the initial removal attempt of the tooth. Tooth #31, which is intact, is seen distal to this root fragment on the provided x-ray. A surgical extraction, as noted under the Plan, would require a flap and removal of bone to qualify as such a surgical procedure. It appears that this would require such intervention to remove the root. The procedure code would be appropriate for this condition, and would be medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the extraction services have been met. Therefore, we decided that the Plan has to pre-approve the extraction of roots with bone (CPT D7250) for tooth #30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased September 30, 2019.
You asked the Plan to pay for hearing aids are covered only when purchased from the provider. You say that you had called the plan before your hearing test appointment to determine your benefit. The representative did not inform you of the specific supplier required for purchasing hearing aids. The Plan denied your request. The Plan says hearing aids purchased from a vendor other than the provider is not a covered benefit.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only hearing aids. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of hearing aids are covered only when purchased fromthe provider have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased September 30, 2019.