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

We decided that the Plan does not have to pay for polysomnography, split-night study (95811) provided August 11, 2020.
You asked the Plan to pay for the polysomnography. You say that payment has been made for the technical component and payment is needing to be made for the read. Please reprocess claim for payment. The Plan denied your request. The Plan says a polysomnography service should be reported within one year of a comprehensive sleep evaluation and was not found.
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, we find that CPT code 95811 is not supported in the medical record. Specifically, the code submitted for payment cannot be substantiated by a face to face or in lab sleep study which would be required. Based on this information, we decided that Medicare rules for coverage of the polysomnography have not been met. Therefore, we decided that the Plan does not have to pay for polysomnography, split-night study (95811) provided August 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1851) for the enrollee.
You asked the Plan to pre-approve the orthosis. You say that this is medically necessary. The Plan denied your
request. The Plan says the request was made in good faith before the enrollee's condition got worse.
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 orthosis. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found in this case, the record does not indicate that the enrollee has had a recent injury or a surgical procedure.
The documentation indicates there is no instability. Therefore, the criteria of the local coverage determination
are not satisfied, and the requested knee orthosis cannot be recommended.
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 orthosis have not been met. Therefore, we decided that the Plan does not
have to pre-approve a knee orthosis (L1851) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carboplatin, Pembrolizumab, Gemcitabine, Palonosetron and Dexamethasone for the enrollee.
You asked the Plan to pre-approve these drugs. You say that these drugs are medically necessary. The Plan denied your request. The Plan says that there is no support in the compendia utilized by Medicare or in Medicare approved medical journals for the regimen consisting of Carboplatin, Pembrolizumab, Gemcitabine, Palonosetron and Dexamethasone for the member's disease.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 these drugs. Our reviewer says that these drugs are not medically reasonable and necessary for the enrollee. The use of Carboplatin, Pembrolizumab, Gemcitabine, Palonosetron and Dexamethasone are not FDA-approved for the enrollee's diagnosis. The use of these drugs is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use of these drugs is not listed as not indicated, not supported or not recommended in any of the compendia. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these drugs. 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 drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Carboplatin, Pembrolizumab, Gemcitabine, Palonosetron and Dexamethasone for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the lower extremity.

You asked the Plan to pre-approve an MRI of the lower extremity. You say that the requested MRI of the lower extremity while in Michigan is medically necessary. The Plan denied your request. The Plan says the requested MRI of the lower extremity is not medically necessary as the enrollee can receive this service with an in-network provider when she returns to the Plan's service area.

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 an MRI of the lower extremity. Our reviewer says that the requested MRI of the lower extremity while in Michigan is not medically necessary. Our physician reviewer found the enrollee is currently in Michigan, out of the plan's service area, due to her son having a rare blood cancer. While in Michigan she started developing intense right knee pain affecting her ability to walk, do normal activities and sleep. She has had several phone and video appointments with her Plan providers. Her in-network provider ordered an x-ray to be done in Michigan, which the Plan approved. Now the provider is requesting an MRI of the knee to be provided as the enrollee is not returning to the Plan's service area for months. 

There is no documentation of a 6-week trial of physical therapy for knee pain. There are no red flags for an MRI at this time. 

More conservative measures are needed 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 an MRI of the lower extremity have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI of the lower extremity.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient hospital care from February 21, 2021 and forward.
You asked the Plan to pre-approve continued inpatient hospital care. You say that the requested continued inpatient hospital care from 2/21/21 and forward is medically necessary. The Plan denied your request. The Plan says the requested continued inpatient hospital care from 2/21/21 and forward is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued inpatient hospital care. Our reviewer says that the requested continued inpatient hospital care from 2/21/21 and forward is not medically necessary. Our physician reviewer found the enrollee presented to the emergency room on 2/3/21 with acute mental status changes. The evaluation revealed +Covid 19 and aspiration pneumonia. She was treated with IV fluids and IV antibiotics. She subsequently developed a Pseudomonas urinary tract infection. She was transferred to palliative care on 2/22/2021. The review indicates that the enrollee did not require inpatient hospital level of care services from February 21, 2021 and forward. The review has determined that the requested continuation of inpatient hospital care from February 21, 2021 and forward is not medically reasonable or necessary 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 continued inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient hospital care from February 21, 2021 and forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator system.
You asked the Plan to pre-approve a spinal cord stimulator system. You say that the requested spinal cord stimulator system is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested spinal cord stimulator system.
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 spinal cord stimulator system. Our reviewer says that the enrollee does not meet criteria for the requested spinal cord stimulator system. Our physician reviewer found the enrollee has chronic low back pain. She had radiofrequency ablation of her lumbar facets and had only 2 months of pain relief. She is taking Morphine and Norco for pain. She has not had a trial of physical therapy. She had a psychological evaluation and was cleared for a SCS trial. An MRI demonstrated Scoliosis, Degenerative disc disease with a disc protrusion, forminal stenosis at multiple levels and facet arthropathy. She has not had any prior spine surgery, or any other evidence based indication for a SCS trial. She has not had a surgical consultation. The enrollee does not have an evidence based indication for a SCS trial. She has not had a surgical consultation to address her disc protrusion, neural forminal stenosis or her scoliosis. She has not had Physical Therapy. The request is not medically reasonable or 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 a spinal cord stimulator system have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator system.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 27, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the diagnosis is not valid.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The file shows that the claim was billed with diagnosis codes indicating laterality when a more specific bilateral code is appropriate. 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 pay for the laboratory services rendered on May 27, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from September 17, 2020, to October 16, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee required no nursing services which would be considered skilled services by Medicare.
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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on 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 the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from September 17, 2020, to October 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

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. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on September 1, 2020.
You asked the Plan to pay for train of four testing. You say that this service was medically necessary. The Plan denied your request. The Plan says this service is not separately payable.
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 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other intraoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on September 1, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises.

You asked the Plan to pay for the therapeutic exercises. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the therapeutic exercises.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve the continuous glucose monitor. You say that the CGM is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 the continuous glucose monitor. Our reviewer says that the CGM is not medically necessary. Our physician reviewer found per the documentation the enrollee dose not check his blood glucose more than four times per day and does not take more than three insulin injections with frequent dose adjustments. 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 continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 48 units of physical therapy.
You asked the Plan to pre-approve the additional physical therapy. You say that you would like reconsideration because the additional physical therapy is medically necessary. The Plan denied your request. The Plan says these services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the member's current condition or to prevent or slow further deterioration. 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 additional physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 48 units of physical therapy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulicity for the enrollee.
You asked the Plan to pre-approve Trulicity. You say that this is medically necessary. The Plan denied your
request. The Plan says that this 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-approve Trulicity for the enrollee.
Benefits for Trulicity may be available under Medicare Part D. Contact the 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 a computed tomography (CT) scan of the chest (71260) and of the abdomen and pelvis (74177).
You asked the Plan to pre-approve CT scans. You say that these scans are medically necessary. The Plan denied your request. The Plan says the requested scans are not indicated at this time.
The Plan must follow Medicare rules. Medicare rules say that CT 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 CT scans. Our reviewer says that the requested CT scans are not medically necessary in this case. Our physician reviewer found the submitted records from November 2020 do not indicate that there were any concerning symptoms or physical examination findings. Furthermore, the CT scan of October 2020 did not demonstrate recurrent disease. Therefore, a routine CT scan at this time is not medically reasonable or necessary and cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scans have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest (71260) and of the abdomen and pelvis (74177).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the professional services for the administration of immunotherapy (G0069) provided on August 18, 2020.

You asked the Plan to pay for the professional services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support 32 units of 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. 

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 professional services. Our reviewer says that CPT code G0069 does not meet criteria for billing or reimbursement consideration. Our reviewer found the home visit note documents start time 07:50 and end time 14:15. 07:50 to 14:15 equals 360 minutes divided by 15 minute increments equals 26 units to report. 

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 professional services have not been met. Therefore, we decided that the Plan does not have to pay for the professional services for the administration of immunotherapy (G0069) provided on August 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Infliximab injection (J1745).

You asked the Plan to waive the coinsurance for the Infliximab injection. You say that to cost of the injection is too high. The Plan denied your request. The Plan says the coinsurance was 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 20% coinsurance for the total cost of Medicare covered Part B drugs.

You have been asked to pay a total of $716.80 ($3,584.00 total allowed amount x 20% coinsurance) for the Infliximab injection. Infliximab injections fall within the Outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Infliximab injection (J1745).