Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical documentation does not show how this would help in the home.
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 wheelchair. Our reviewer says that the requested wheelchair is not considered medically reasonable and necessary in this case. Our physician reviewer found the clinical documentation does not support the need for a power wheelchair. There is no documentation of how it would benefit ADLs in the home. Additionally, you have poor vision and forgetfulness, which would make it unsafe to operate the wheelchair. 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 power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve left knee radiofrequency ablation (64624).
You asked the Plan to pre-approve left knee radiofrequency ablation. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.
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 left knee radiofrequency ablation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental procedure that is the subject of on-going clinical trials. Therefore, the request is considered 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 left knee radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve left knee radiofrequency ablation (64624).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on December 16, 2019. You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that you were outpatient and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct 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 $250 copayment for advanced imaging services provided in an outpatient hospital facility. You have been asked to pay a $250 copayment for myocardial perfusion imaging. Myocardial perfusion imaging falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on December 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that the enrollee would do much better with this drug. The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or intolerance to Monovisc and Orthovisc.
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 Euflexxa. Our reviewer says that the drug is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of unilateral primary osteoarthritis of the right knee. The enrollee has not tried and failed the required drugs. The documentation does not support that Monovisc and Orthovisc (Hyaluronic acid) 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
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 the home ventilator. You say that , due to the enrollee's advanced disease, she requires a ventilator for home use to reduce the work of breathing and to improve pulmonary status. You say that, without home ventilation, the enrollee may suffer a decline in health due to CO2 retention or recurrent hospitalizations.The Plan denied your request. The Plan says the requested device is not medically necessary.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 the home ventilator. Our reviewer says that the coverage criteria have not been met. Our physician reviewer found the enrollee has severe COPD, but the records provided do not include documentation of CO2 retention. She has been using a home ventilator since 2018, but it is being used as a BiPAP device, which is not covered by Medicare. There are BiPAP devices that provide the AVAPS-AE mode of ventilation. The enrollee may qualify for BiPAP, if there is documentation of CO2 retention when in a stable state. A home ventilator is not 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 the home ventilator have not been met.Therefore, we decided that the Plan does not have to pre-approvea home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on May 2, 2019.You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 00811 is anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified.We find that CPT code 00811 is not supported in the medical record. Specifically, the documentation submitted did not support 758 units of this code. The submitted medical records indicate that anesthesia start time was 11:22 and the anesthesia stop time is 12:00. Therefore, 758 units is not supported. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met.Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on May 2, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 76881) provided on August 9, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service cannot be verified.
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 76881 is "Ultrasound, complete joint (ie, joint space and peri-articular soft-tissue structures), real-time with image documentation". 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 use of CPT code 76881 is not supported by the records provided. Our coding reviewer found that the medical records provided do not include documentation of an "Ultrasound, complete joint (ie, joint space and peri-articular soft tissue structures) real-time with image documentation", therefore this service cannot be validated. 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 for the services (CPT 76881) provided on August 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network
provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee does not have out-of-network benefits.
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 to an out-of-network provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT scan of the chest.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that there is insufficient documentation to substantiate the medical necessity of this scan 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 the scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found since she is age 55-74 with at least a 30 pack-year history of smoking and quit within the last 15 years with no life limiting conditions annual screening with low dose helical chest CT scan is recommended by the US preventative task force guidelines in this subset of patients. Studies have demonstrated improved outcomes with screening chest CT scanning in this patient subset compared to screening with chest x-ray alone. Therefore the requested chest CT scan is 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 the scan have been met. Therefore, we decided that the Plan has to pre-approve CT scan of the chest. If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied your request. The Plan says the requested orthotics are not part of a brace.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99223, CPT 99239) provided on September 14, 2019 and September 15, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee was not under inpatient status.
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 99223 and 99239 are not supported in the medical record. Specifically, these codes are used to represent inpatient services. The enrollee was not an inpatient during this episode of care. It is inappropriate to bill inpatient CPT codes, for outpatient services. 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 for the services (CPT 99223, CPT 99239) provided on September 14, 2019 and September 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and related medical services provided on April 15, 2019 by an out of network (OON) provider. You asked the Plan to pay for the office visit and related medical services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 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 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 and related medical services provided on April 15, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Kanjinti.
You asked the Plan to pre-approve Kanjinti. You say that the medication is 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 Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Kanjinti. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the enrollee has been treated with chemotherapy with the most recent regimen completed in October 2019. The enrollee has disease recurrence. Documentation supports extensive consultation and the enrollee is currently declining chemotherapy treatment. Kanjinti is being prescribed as monotherapy. Review of approved compendia and literature does not support monotherapy with this agent. The regimen is not supported and cannot be determined 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 Kanjinti have not been met. Therefore, we decided that the Plan does not have to pre-approve Kanjinti.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided to the enrollee on November 29, 2019.You asked the Plan to pay for ambulance services. You say that the services were necessary due to enrollee's immobility.The Plan denied your request. The Plan says Original Medicare is responsible for all Medicare-covered non-hospice services.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 ambulance services provided to the enrollee on November 29, 2019
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from September 19, 2019 to September 26, 2019.
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 claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that value codes are required for home health claims. We looked at the file and Medicare rules. The claims were billed with the incorrect value code. 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 home health services rendered from September 19, 2019 to September 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair options and accessories.You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the enrollee has no postural asymmetries, no pelvic asymmetries, and no pelvic obliquity.The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered under certain medical indications.The file shows that wheelchair transport brackets were requested. We looked at the file and the rules. 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.The file shows that an 8-way rocker was requested. We looked at the file and the rules. Code K0108 must not be used for any component or feature of an expandable controller at the time of initial issue.Based on this information, we decided that the Medicare rules for coverage have not been met.The file shows that a positioning wheelchair back cushion (Code E2620), and ask in protection and positioning wheelchair seat cushion (Code E2624) were requested. 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 requested items. Our physician reviewer found that the back cushion (E2620) is not medically necessary as you have no evidence of any significant postural asymmetries. The combination skin protection and positioning seat cushion (E2624) is not medically necessary as you do not meets the criteria for both a skin protection seat cushion and a positioning seat cushion.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 requested items have not been met.Therefore, we decided that the Plan does not have to pre-approve wheelchair options and accessories.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a podiatrist consultation.
You asked the Plan to pre-approve the consultation. You say that this is medically necessary. The Plan denied your request. The Plan says that the records do not show pain, limited walking, or secondary infection.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the consultation. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the primary care physician's progress note dated 3/10/2020 advises that you are suffering with painful onychomycosis bilateral feet, painful bunions, and painful ankle right greater than left. Your appeal letter states that the pain to your ankles is inhibiting normal comfortable ambulation. You are also noted to have painful bunions. You deserve a consultation with a podiatrist to help treat these painful ailments. A visit with a podiatrist in order to evaluate the above mentioned pathologies is certainly considered standard of care, safe, effective, and appropriate. 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 consultation have been met. Therefore, we decided that the Plan has to pre-approve a podiatrist consultation.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Siliq for the enrollee.
You asked the Plan to pre-approve this drug. You say that this drug is effective for psoriasis and psoriatic arthritis. The Plan denied your request. The Plan says that this is not covered by the enrollee's plan.
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 Siliq for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.