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

We decided that the Plan does not have to pay for the services provided on December 13, 2019.
You asked the Plan to pay. You say that your wife had the same service, and was reimbursed. The Plan denied your request. The Plan says the service is considered not proven effective.
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. The stent drainage device is considered not medically reasonable and necessary. 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 services provided on December 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for TC-99m (Q9969) and aminophyllin injection (J0280) provided on September 11, 2019. You asked the Plan to pay for the TC-99m and injection. 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 services 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 CPT Code Manual definition of code Q9969 is Tc-99m from non-highly enriched uranium source, full cost recovery add-on, per study dose. The CPT Code Manual definition of code J0280 is injection, aminophyllin, up to 250 mg. 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 TC-99m and injection. Our reviewer says that CPT code Q9969 does not meet criteria for billing or reimbursement consideration. The documentation indicates Sestambi was administered, which does not meet the definition for HCPCS code Q9969. Our reviewer found CPT code J0280 does not meet criteria for billing or reimbursement consideration.  The medical records submitted do not include documentation of an injection, aminophyllin, up to 250 mg being performed on September 11, 2019, therefore, this code cannot be verified. 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 TC-99m and injection have not been met. Therefore, we decided that the Plan does not have to pay for TC-99m (Q9969) and aminophyllin injection (J0280) provided on September 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aloxi, dexamethasone sodium phosphate, diphenhydramine HCL, fosaprepitant, and famotidine. 
 
You asked the Plan to pre-approve Aloxi, dexamethasone sodium phosphate, diphenhydramine HCL, fosaprepitant, and famotidine. You say that the requested drug regime (Aloxi, dexamethasone sodium phosphate, diphenhydramine HCL, fosaprepitant, and famotidine) to treat nausea related to chemotherapy is medically necessary. The Plan denied your request. The Plan says the requested drug regime (Aloxi, dexamethasone sodium phosphate, diphenhydramine HCL, fosaprepitant, and famotidine) to treat nausea related to chemotherapy is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved 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 Aloxi, dexamethasone sodium phosphate, diphenhydramine HCL, fosaprepitant, and famotidine. Our reviewer says that the requested drug regime (Aloxi, dexamethasone sodium phosphate, diphenhydramine HCL, fosaprepitant, and famotidine) to treat nausea related to chemotherapy is not medically necessary. Our physician reviewer found Abraxane carries a low risk of emetogenic potential. Aloxi, dexamethasone, and fosaprepritant are a standard regimen for highly or moderately emetogenic chemotherapy regimens. The regimen is not a standard of care for use with abraxane and is not FDA approved, supported by major drug compendia, or the medical literature. The service is 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 Aloxi, dexamethasone sodium phosphate, diphenhydramine HCL, fosaprepitant, and famotidine have not been met. Therefore, we decided that the Plan does not have to pre-approve Aloxi, dexamethasone sodium phosphate, diphenhydramine HCL, fosaprepitant, and famotidine.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home visits for assistance with activities of daily living and
personal care (99509) provided from July 16, 2019 to September 29, 2019.
You asked the Plan to pay for home visits. You say that these services were approved by your physician. The
Plan denied your request. The Plan says these services are not covered.
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 code 99509 is not supported in the medical record. Specifically, this code has a status
indicator of "I." Medicare uses another code for reporting of, and payment for these services. These services
cannot be paid as billed. Based on this information, we decided that Medicare rules for coverage of home visits
have not been met. Therefore, we decided that the Plan does not have to pay for home visits for assistance with
activities of daily living and personal care (99509) provided from July 16, 2019 to September 29, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for PET imaging (78812), CT of the abdomen and pelvis (74176), CT of the neck (70490) and CT of the thorax (71250) provided on November 25, 2019. You asked the Plan to pay for the PET and CT imaging. 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 services billed. The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PET and CT imaging have not been met. Specifically, the record does not include the actual date of service. There is insufficient information to verify the services billed. Therefore, we decided that the Plan does not have to pay for PET imaging (78812), CT of the abdomen and pelvis (74176), CT of the neck (70490) and CT of the thorax (71250) provided on November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for urinary catheters (A4352) provided on April 26, 2019.
You asked the Plan to pay for the urinary catheters. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery.
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 physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The delivery ticket submitted did not include the carrier's tracking number and the proof of delivery did not include an order number or details to corroborate the delivery ticket. Therefore, we decided that the Plan does not have to pay for urinary catheters (A4352) provided on April 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a radiologic examination provided on December 19, 2019.
You asked the Plan to pay for the radiologic examination. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a radiologic examination provided on December 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1399).
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the requested item is needed. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1399).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for intensity modulated radiation therapy with stereoscopic x-ray guidance with you, an out-of-network provider, for the enrollee.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says care must be received with in-network providers.
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 referral for an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that you would like reconsideration because this procedure is less invasive and you are a good candidate. The Plan denied your request. The Plan says there is poor evidence and outcomes to support performing this procedure.
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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental and more research is needed to show its safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Portable Oxygen Concentrator purchased on October 17,
2019 from a non-Medicare provider.
You asked the Plan to pay for the portable oxygen concentrator. You say that you are requesting
reimbursement of services rendered. The Plan denied your request. The Plan says the Medicare rules have not
been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the portable oxygen concentrator have not been met. Only rented
oxygen equipment is eligible for coverage. Purchased oxygen equipment is statutorily non-covered.
Furthermore, the provider is not Medicare certified. Therefore, we decided that the Plan does not have to pay
for Portable Oxygen Concentrator purchased on October 17, 2019 from a non-Medicare provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833) and suspension sleeve (L2397) provided to the enrollee on January 16, 2020.
You asked the Plan to pay for the orthosis and sleeve. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis and sleeve have not been met. Review of the file shows that the documentation submitted did not support the diagnosis used on the submitted order, nor did the documentation indicate the provider discussed the need for the billed supply code; therefore the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1833) and suspension sleeve (L2397) provided to the enrollee on January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for (D9630), (D4921), (D4381), (D4342), (D4341) and (D0431) provided on September 4, 2019.
You asked the Plan to pay for the dental services. You say that the provider told you that the services were going to be covered. The Plan denied your request. The Plan says the services are not a covered benefit under the plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The services are not listed in your EOC as a covered benefit; therefore, they are not covered Therefore, we decided that the Plan does not have to pay for (D9630), (D4921), (D4381), (D4342), (D4341) and (D0431) provided on September 4, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the Health Plan has no contractual obligation to cover services that are not medically necessary or that do not meet Medicare criteria for coverage.
The 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 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services to safely and effectively provide medically necessary and reasonable treatment in a SNF. There are no complex wounds, new enteral feedings, or other SN level need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment only in a SNF. The skilled services are not needed on a "daily basis" in a SNF. As a practical matter this enrollee does not require the necessary services on 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second medial branch block (MBB) injection.
You asked the Plan to pre-approve these services. You say that you would like a second MBB to determine the necessity of radiofrequency ablation. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MBBs are covered when specific criteria are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have chronic low back pain. You had a first set of diagnostic MBBs with 75 percent pain relief. This does not meet the Medicare criteria of a positive block. The second MBB is 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 second medial branch block (MBB) injection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on January 25, 2020 through February 1, 2020.You asked the Plan to pay for home infusion therapy. You say that you would like reconsideration because CPT code S9328 is valid per CMS.The Plan denied your request. The Plan says CPT code S9328 has a status code of I which is not valid for Medicare purposes.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 code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status code of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on January 25, 2020 through February 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on December 12, 2018 from an out-of-network provider.
You asked the Plan to pay for the hearing aids. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says the provider is not part of the vendor network.
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. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. The provider is not in-network and your EOC clearly states, hearing aids must be ordered directly from the plan's supplemental hearing vendor. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased on December 12, 2018 from an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve phonopheresis.
You asked the Plan to pre-approve the services. You say that the enrollee has been having a lot of pain in the ankle and heel. The Plan denied your request. The Plan says there are no medical indications for the use of this technology.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found studies advise that the efficacy of phonophoresis does not appear to be greater than placebo. According to the literature, it does not appear that this modality is effective, or furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member. It does appear that phonophoresis is still considered investigational, with more double-blind placebo-controlled studies required in order to confirm its effectiveness. The requested phonopheresis is not medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve phonopheresis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may benefit from additional multiple therapies, however the enrollee was noted to have fatigue and pain on May 15 in therapy. She does not require IRF level therapy or appear to have the endurance to tolerate therapy in an IRF with an intensive level program. 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 Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.