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

We decided that the Plan does not have to pre-approve Reblozyl.

You asked the Plan to pre-approve Reblozyl. The Plan denied your request. The Plan says the use is not supported for the treatment of anemia in this enrollee.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Reblozyl. Our physician reviewer found that the enrollee has rheumatoid arthritis with ringed sideroblasts. The requested use of Reblozyl is not FDA-approved for the enrollee's diagnosis. He has not been transfused and does not have thrombocytosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does not support that the requested drug is safe and effective and otherwise 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 Reblozyl have not been met. Therefore, we decided that the Plan does not have to pre-approve Reblozyl.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the contact lenses purchased December 28, 2020.

You asked the Plan to pay for the contact lenses. You say that you did not have the 2021 Evidence of Coverage and did not know you needed to use a network provider. The Plan denied your request. The Plan says the contact lenses were purchased in 2020, and the 2020 Evidence of Coverage clearly states you must use a network provider.

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 purchased within the Plan's vision care network. 

We looked at the file and the Plan's rules. You did not purchase the contact lenses within the Plan's vision care network. Based on this information, we decided that the Plan's rules for coverage of the contact lenses have not been met. Therefore, we decided that the Plan does not have to pay for the contact lenses purchased December 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on October 28, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that the service was medically necessary. 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 office visit provided on October 28, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0425, A0429) provided November 14, 2020.

You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services are not eligible for payment.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT codes A0425, & A0429 are not supported in the medical record. Specifically, the record shows the enrollee was an inpatient at the time services were provided. Transportation between two facilities while an enrollee is an inpatient is included in payment for the inpatient services.

Ambulance services are not separately payable. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0425, A0429) provided November 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.

You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a home ventilator.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.

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 home ventilator. Our reviewer says that the enrollee does not meet criteria for a home ventilator. Our physician reviewer found a home ventilator is considered not medically necessary. This enrollee has chronic hypercapnic respiratory failure, likely due to both COPD and obesity hypoventilation syndrome. The enrollee may benefit from positive airway pressure during sleep.

Certain BiPAP devices can provide the AVAPS mode of support that has been ordered for the ventilator, and Medicare does not cover a home ventilator when used as BiPAP. There is no documented failure of BiPAP.

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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the repair of a biceps tendon (23430-59) provided on December 16, 2020.

You asked the Plan to pay for the repair of a biceps tendon. You say that this was billed correctly. The Plan denied your request. The Plan says modifier -59 is not appropriate.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.

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 pay for the repair of a biceps tendon Our reviewer says that the records do not support the use of modifier -59. Our physician reviewer found the operative report does not document the biceps tendon as a distinct procedure from the shoulder joint reconstruction.

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 repair of a biceps tendon have not been met. Therefore, we decided that the Plan does not have to pay for the repair of a biceps tendon (23430-59) provided on December 16, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that you can get better faster with supervised therapy
and direct care. The Plan denied your request. The Plan says that the assistance and supervision that you need
does not need to be given in a Skilled Nursing Facility.

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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on February 10, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the domiciliary visit. You say that the hospital staff is responsible for verifying eligibility and to obtain the proper authorization. You say the services were medically necessary. 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 domiciliary visit provided on February 10, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 3, 2020.

You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as billed.

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 HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. 

We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. 

Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. 

Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam (92012) received January 14, 2021.

You asked the Plan to pay for the eye exam. You say that the provider did not require a referral to treat the
patient. The Plan denied your request. The Plan says the provider does not participate in the Plan's vision
network and a referral was not obtained from a network provider for the service.

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 obtained from a network provider.

We looked at the file and the Plan's rules. The eye exam was obtained outside of the Plan's vision network, and
the provider did not obtain a referral for the services. Based on this information, we decided that the Plan's
rules for coverage of the eye exam have not been met. Therefore, we decided that the Plan does not have to pay
for the eye exam (92012) received January 14, 2021.
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. The Plan denied your request. The Plan says you have
not completed your full course of care in the 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 physician
reviewer found that you were admitted to the acute care hospital with a retroperitoneal hematoma and
developed acute kidney injury and respiratory failure. You are not clinically stable. You continue to receive
acute care services, and these have not been denied. The medical record does not indicate that you require
services that you are not currently receiving but that would be available at the LTACH facility.

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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power scooter group 1 standard, weight capacity up to and including 300 pounds (K0800) power wheelchair accessory, u-1 sealed lead acid battery (E2365) power wheelchair accessory, battery charger, single mode, for use with only one battery type, sealed or non-sealed (E2366).

You asked the Plan to pre-approve the power scooter and accessories. You say that the enrollee is unable to walk more than 3 feet of distance without being out of breath. The enrollee will benefit for use in his daily MRADL's (bathing, walking, cooking and moving around the house). The Plan denied your request. The Plan says the requested power scooter and accessories is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

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 power scooter and accessories. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not clearly indicate the enrollee has a mobility deficit that impairs MRADL's in the home and is not ameliorated by a walker, cane, manual wheelchair. The documentation is not clear that the patient can safely operate and maneuver the requested power operated vehicle in the home.

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 power scooter and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve power scooter group 1 standard, weight capacity up to and including 300 pounds (K0800) power wheelchair accessory, u-1 sealed lead acid battery (E2365) power wheelchair accessory, battery charger, single mode, for use with only one battery type, sealed or non-sealed (E2366).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care provided on February 16, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the wound care. You say that the service was medically necessary. 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 wound care provided on February 16, 2021 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power options and accessories.

You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options and accessories. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with multiple power options is covered if the enrollee meets the coverage criteria for a power tilt and recline seating system or the system is being used on the wheelchair of the beneficiary uses a ventilator which is mounted on the wheelchair 

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 group 3 power wheelchair with multiple power options and accessories. Our reviewer says that the requested power wheelchair is not medically necessary. Our physician reviewer found that the requested Group 3 power wheelchair with multiple power options is not medically necessary per Medicare Guidelines. The patient has a qualifying Group 3 diagnosis of post-polio syndrome. However, the patient does not use a ventilator mounted to the wheelchair and does not meet coverage criteria for a power tilt and power recline seating system. There is no evidence of intermittent catheterization, spasticity that needs to be managed with power seating, or evidence of being high risk for a pressure ulcer. 

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 group 3 power wheelchair with multiple power options and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power options and accessories.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cytopathology provided on January 21, 2021.

You asked the Plan to waive the copayment for the cytopathology. You say that you do not believe there was any test or urine sample taken during your doctor's visit. 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 $10 copayment per visit for laboratory tests, non-radiological tests, non-radiological tests, flat film x-rays, and ultrasounds. 

You have been asked to pay a $10 copayment for the cytopathology. The cytopathology falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows a urine specimen was collected and tested on this date of service.

This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the cytopathology provided on January 21, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. You say that you cannot see the labels on your medications. The Plan denied your request. The Plan says you have no skilled nursing needs, and do not require skilled therapy on a daily basis.

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 services. Our physician reviewer found that from a nursing perspective, you received oral medications, had stable vital signs, and were treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, you were at a supervision to contact guard assist level with functional mobility. You required varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.