Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve the home health services. You say that you have not met your goal because you have lost your balance quite a few times. You say that you want to continue physical therapy so that you do not have the fear of falling. You say that you have trouble walking up 5 steps in your home. The Plan denied your request. The Plan says home physical therapy is not medically necessary.
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 home health services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the medical records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services which are medically necessary for the enrollee. The enrollee has had prior physical therapy services and the notes indicate that he was trained in a home exercise and that no additional physical therapy visits are needed currently. The enrollee should be able to transition to an independent home exercise program. The enrollee's functional level and chronic weakness do not require the ongoing professional skills of a therapist for the treatment of his 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 the home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on September 3, 2019.You asked the Plan to waive the copayment forthe office visit. You say that the charges happened on the same visit. You say that you should not be charged twice.The Plan denied your request. The Plan says the copayment applied correctly.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 $40 copayment for provider and professional services at an in-network specialist's office. You have been asked to pay a $40 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 forthe office visit provided on September 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forinjection services provided to the enrollee on October 4, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says CPT 20610 was denied for a missing modifier, and HCPCS J7325 was denied because the qualified procedure was not processed or paid.The Plan must follow Medicare rules. Medicare rulessay that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of the denied codes is:CPT 20610:Arthrocentesis, aspiration and/or injectionHCPCS J7325:Hyaluronan or derivative, synvisc or synvisc-one, for intra-articular injection, 1 mg We asked our coding 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 pay for the services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found the medical records provided indicate that Arthrocentesis, aspiration and/or injection was performed on the date of service 10/04/2019, however, when the claim was billed to the health plan, CPT code 20610 was submitted without a required modifier to indicate if the Arthrocentesis, aspiration and/or injection was performed on the right side, left side or bilaterally. Therefore, since the claim was not billed correctly according to Medicare rules, CPT 20610 is not eligible for reimbursement. The qualifying primary procedure 20610 was not eligible for reimbursement because it was missing a necessary modifier. As a result, HCPCS/CPT code J7325 is also ineligible for reimbursement.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 services have not been met.Therefore, we decided that the Plan does not have to pay forinjection services provided to the enrollee on October 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for the drug Budesonide.You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says this is not a Part D drug.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 20% coinsurance for Medicare Part B drugs. The drug in question is a Part B drug. Tier exceptions can only be granted under your plan for Part D drugs. Per your plan contract, you have a 20% coinsurance responsibility for Part B drugs. This means that you are being 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 pre-approve a tier exception for the drug Budesonide.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nucala for the enrollee.You asked the Plan to pre-approveNucala. The Plan denied your request. The Plan says that this medication is not covered 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 drug requested here is not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveNucala for the enrollee.Benefits for Nucalamay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
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 you would like reconsideration based on the records submitted. The Plan denied your request. The Plan saysthe shower chair is not a Medicare 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standard manual wheelchair (K0001).
You asked the Plan to pre-approve the wheelchair. You say that this service/item is medically necessary. The
Plan denied your request. The Plan says medical necessity criteria have not been met.
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 wheelchair. Our reviewer says that
the documentation does not support that the requirements for Medicare coverage have been met based on the
LCD. Our physician reviewer found according to the physician note dated January 22, 2020, the enrollee is
alert and oriented to person only, confused, and has impaired judgement and insight. The documentation
reveals she lives in an assisted living facility and uses a manual wheelchair to ambulate. The progress report
notes the enrollee requires a wheelchair for ambulation per staff, and due to dementia, she is unable to
comprehend how to use a cane or walker. The documentation is not clear whether the use of a manual
wheelchair will significantly improve the enrollee's ability to participate in MRADLs and the enrollee will use
it on a regular basis in the home. The documentation does not support that the enrollee has the cognitive ability
to safely maneuver the wheelchair on her own. The documentation does not reveal that the enrollee has a
caregiver who is available, willing, and able to provide assistance with the wheelchair. For these reasons the
documentation does not support that the manual wheelchair is medically reasonable and necessary for this
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 wheelchair have not been met. Therefore, we decided that the Plan does not
have to pre-approve a standard manual wheelchair (K0001).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on July 9, 2019.You asked the Plan to pay for the orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This meansthat the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on July 9, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.You asked the Plan to pre-approvethe SNF admission. You say that the enrollee has difficulty walking and constantly falls due tobeing very unstable. She has early stages of dementia and needs guidance with taking medication.The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care such as home with supervision and home health services or long term care with intermittent servicesThe Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefullyreview the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does have skilled therapy service needs but does not require skilled therapy on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approvethe skilled nursing facility (SNF) admission.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient lab work provided on September 16, 2019 by an out of network (OON) provider.You asked the Plan to pay foroutpatient lab work. You say that you completed the lab work that was sent to you.The Plan denied your request. The Plan says the referring provider is out of network. The Plan says that no prior authorization was obtained 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We foundno exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay foroutpatient lab work provided on September 16, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the knee (73721).You asked the Plan to pre-approvethe MRI. You say that the MRI is medically necessary.The Plan denied your request. The Plan says coverage criteria was not met.The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the MRI is not medically necessary at this time. Our physician reviewer found the documentation did not include any physical examination of the knee. There is mention of physical therapy for the low back but not for the knee. There is no plain film imaging of the knee included.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 MRI have not been met.Therefore, we decided that the Plan does not have to pre-approveMagnetic Resonance Imaging (MRI) of the knee (73721).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lyrica capsules 100mg for the enrollee.You asked the Plan to pre-approve the capsules. You say that this is medically necessary.The Plan denied your request. The Plan says this is not a Part B drug.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 Lyrica capsules 100mg for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveBrovana.You asked the Plan to pre-approveBrovana. You say that the requested Brovana is medically necessary.The Plan denied your request. The Plansays the enrollee must try and fail Perforomist first.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 Brovana. Our reviewer says that thePlan's step therapy criteria have not been met. Our physician reviewer found the enrollee has a diagnosis of chronic obstructive pulmonary disease, unspecified. The Plan requires a trial of Perforomist first before they will approve the requested drug, Brovana. Based on the documentation provided, the enrollee has not tried and failed the required drug, Perforomist first. The documentation does not support that Perforomist (formoterol) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Brovana have not been met.Therefore, we decided that the Plan does not have to pre-approveBrovana.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the excision of a benign tumor or cyst (21030), initial 15 minutes of general anesthesia (D9222), additional 15 minutes of general anesthesia (D9223) provided on September 9, 2019.You asked the Plan to pay forthe excision of the tumor or cyst, and the general anesthesia. The Plan denied your request. The Plan says the dental services that were rendered to the enrollee are not covered services.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay forthe excision of a benign tumor or cyst (21030), initial 15 minutes of general anesthesia (D9222), additional 15 minutes of general anesthesia (D9223) provided on September 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Planto pre-approveIRF care. You say that it is felt that IRF care would be the best option for this enrollee.The Plandenied your request. The Plansaysthe IRF criteria are not met in this case.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 based on review of the available records, the patient does not meet criteria for IRF admission. The patient was medically stable with no evidence of need for supervision by PMR Physician or needs acute rehab nursing care. He may benefit from further PT and an OT but does not require an intensive therapy program. IRF admission is not medically necessary based slow functional progress and low endurance and medical stability.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 Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva for the enrollee.
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 step therapy requirement is not met.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has secondary malignant neoplasm of unspecified sites. The Plan requires a trial of pamidronate or zoledronic acid before they will approve the requested drug. The documentation indicates that the enrollee is not a candidate for zoledronic acid but has not tried and/or failed pamidronate therapy. Pamidronate would not likely be less effective or have adverse effects for the enrollee; therefore, Xgeva is not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Xgeva for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc One for enrollee.You asked the Plan to pre-approve these services. You say that the enrollee is in tremendous pain.The Plan denied your request. The Plan says the step therapy requirement is not met.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of right knee pain. The records do not show that she has tried and failed the plan's required drugs of Orthovisc and Monovisc. The documentation does not support that Orthovisc and Monovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case; therefore, Synvisc One is not reasonable or medically necessary 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve Synvisc One for enrollee
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myocardial Perfusion Imaging (78451).You asked the Plan to pre-approve the Myocardial Perfusion Imaging. You say that the imaging is medically necessary.The Plan denied your request. The Plan says rules for coverage have not been met.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 Myocardial Perfusion Imaging. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found Based on the records the patient has some coronary risk but no documented history of heart disease, no documented symptoms of angina and no acute ischemic electrocardiographic changes. The chest pain reported is persistent for weeks and in the setting of "work-related chest trauma" with no documented features concerning for angina. Therefore the records do not support the medical necessity for nuclear stress testing.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 Myocardial Perfusion Imaging have not been met.Therefore, we decided that the Plan does not have to pre-approve Myocardial Perfusion Imaging (78451).