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

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs. The beneficiary does not require skilled 
nursing or therapy services on a daily basis. This beneficiary does 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve dental services to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide this service. Therefore, coverage criteria has not been met. 
 
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 
dental services to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for to pay for ambulance transport provided to the enrollee on 
June 16, 2020. 
 
You asked the Plan to pay for this transport. You say that this claim should be paid. The Plan denied your 
request. The Plan says the provider billed HCPCS code A0429 with QL modifier. The records indicate the 
enrollee was pronounced dead after the ambulance was called. The Plan says that per Medicare Guidelines 
providers report the A0428 (BLS) HCPCS code. Providers report modifier QL (Patient pronounced dead after 
ambulance called) in Form Locator (FL) 44 "HCPCS/Rates" instead of the origin and destination modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case the claim submitted cannot be paid as 
billed due to an issue with the code and the modifier placement. Medicare billing criteria are not met.  
Therefore, we decided that the Plan does not have to pay for to pay for ambulance transport provided to the 
enrollee on June 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forCarbamazepine (80157), Clozapine (80159),  Levetiracetam (80177), Topiramate (80201), Digoxin (80162) and Haloperidol (80173) provided on June 22, 2020.You asked the Plan to pay forthe Carbamazepine, Clozapine, Levetiracetam, Topiramate, Digoxin andHaloperidol. 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 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.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 Carbamazepine, Clozapine, Levetiracetam, Topiramate, Digoxin and Haloperidol. Our reviewer says that CPT codes 80157, 80159, 80177, 80201, 80162 and 80173 do not meet criteria for billing or reimbursement consideration. Our reviewer found Laboratory report documents Urine collection.  Per AMA CPT Guidelines Therapeutic Drug Assays are performed to monitor clinical response to a known, prescribed medication.  The material for examination is whole blood, serum, plasma, or cerebrospinal fluid.Examination is quantitative.  Coding is by present drug; measured metabolites of the drug are included in the code, if performed.   Documentation does not indicate that a blood specimen was collected for CPT codes reported.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 Carbamazepine, Clozapine, Levetiracetam, Topiramate, Digoxin and Haloperidol have not been met.Therefore, we decided that the Plan does not have to pay forCarbamazepine(80157), Clozapine (80159),  Levetiracetam (80177), Topiramate (80201), Digoxin (80162) and Haloperidol (80173) provided on June 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthoses as defined by codes L3960, L1971, L3170, L1851 and L2397 on March 16, 2020.

You asked the Plan to pay for the orthoses. You say that the claims should be paid. 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 for the billed date of service.

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 does not contain a valid proof of delivery and relevant medical records which support medical necessity for the supplies provided in this case. The documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service. Therefore the billed code cannot be verified.  The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the orthoses as defined by codes L3960, L1971, L3170, L1851 and L2397 on March 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approved acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approved IRF care. You say that the IRF admission is medically necessary. The Plan denied your request. The Plan says your needs can be met at a different level of care.

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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper eyelid blepharoplasty.

You asked the Plan to pre-approve the upper eyelid blepharoplasty. You say that you would like reconsideration because it is extremely difficult for you to see. The Plan denied your request. The Plan says guidelines for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the upper eyelid blepharoplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Medicare criteria were not met for upper eyelid blepharoplasty based on the lack of superior visual field loss upon visual field testing.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the upper eyelid blepharoplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve upper eyelid blepharoplasty.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hereditary cardiovascular genetic testing provided on April 
28, 2020. 
 
You asked the Plan to pay for genetic testing. You say that you are appealing with records. The Plan denied 
your request. The Plan says the denial of payment for this testing is correct, because Medicare does not cover 
this testing under the circumstances. 
 
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 pay for genetic testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was diagnosed with cardiac arrhythmias, palpitations, brachycardia, high 
cholesterol, pacemaker presence, and abnormal electrocardiogram (EKG). She has no known history of 
cardiovascular disease in her family. Genetic screening to assess cardiovascular risk is not standard of care and 
has not been shown to lead to improved outcomes compared to treatment and monitoring without genetic 
testing. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pay for hereditary cardiovascular genetic testing provided on April 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
October 8, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network physician 
services provided to the enrollee on October 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva. 
 
You asked the Plan to pre-approve Xgeva. You say that Xgeva is medically necessary. The Plan denied your 
request. The Plan says a trial of Zoledronic Acid is required before alternatives can be considered. 
 
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 Xgeva. Our reviewer says that the 
Xgeva is not medically necessary. Our physician reviewer found there is no documentation of a trial of the plan 
preferred drug, or any documentation showing the plan's preferred drug would be unsafe or ineffective for the 
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 Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided. 
 
You asked the Plan to pay for the services. You say that this plan is the primary insurance. The Plan denied 
your request. The Plan says this is not the member's primary insurance. The Plan states the other insurance the 
member has is the primary and they need to provide the explanation of benefits. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has to receive the 
explanation of benefits from the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the 
Plan does not have to pay for the services provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean expandable controller (E2377), expandable controller harness (E2313), an electro connect (E2311), and a power seat elevation feature (E2300).You asked the Plan to pre-approvean expandable controller (E2377), expandable controller harness (E2313), an electro connect (E2311), and a power seat elevation feature (E2300). You say that the requested expandable controller (E2377), expandable controller harness (E2313), an electro connect (E2311), and a power seat elevation feature to control power tilt, recline and power elevating leg rests through the joystick are medically necessary.The Plan denied your request. The Plan says the requested expandable controller (E2377), expandable controller harness (E2313), an electro connect (E2311), and a power seat elevation feature (E2300) to control power tilt, recline and power elevating leg rests through the joystick are 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 an expandable controller (E2377), expandable controller harness (E2313), an electro connect (E2311), and a power seat elevation feature (E2300). Our reviewer says that the requested expandable controller (E2377), expandable controller harness (E2313), and electro connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick are not medically necessary. Our physician reviewer found the documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array,etc.) The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's upper extremity strength and function are sufficient for the enrollee to control any power options through their own individual switches. Furthermore, a power seat elevation system (E2300) is statutorily non-covered by Medicare and the Plan.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 expandable controller (E2377), expandable controller harness (E2313), an electro connect (E2311), and a power seat elevation feature (E2300) have not been met.Therefore, we decided that the Plan does not have to pre-approvean expandable controller (E2377), expandable controller harness (E2313), an electro connect (E2311), and a power seat elevation feature (E2300).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound services (CPT code 76642) provided on June 
29, 2020. 
 
You asked the Plan to pay for CPT code 76642. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 2. You billed a total of 4 units of this code, exceeding the MUE. 
Based on this information, we decided that Medicare rules for coverage of CPT code 76642 have not been met. 
Therefore, we decided that the Plan does not have to pay for the ultrasound services (CPT code 76642) 
provided on June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee needs a repeat echo due to 
severe aortic stenosis. The Plan denied your request. The Plan says there is no new evidence of significant 
stenosis. 
 
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 requested services. Our physician 
reviewer found that the enrollee has a history of hypertension, COPD, dyslipidemia and aortic valve stenosis. 
Based on the records the enrollee has asymptomatic moderate-to-severe aortic valve stenosis, with no 
documented clinical instability. In this circumstance, a yearly follow up is considered appropriate, and follow 
up less than yearly is not considered 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a transthoracic echocardiography.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) 
joint nerves. 
 
You asked the Plan to pre-approve the RFA procedure. You say that the enrollee would benefit from this 
procedure as medication alone is not a good option. The Plan denied your request. The Plan says this is not a 
proven 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 RFA procedure. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has chronic low back pain with myasthenia gravis. She has also had lumbar 
decompression. She has had 2 diagnostic SI joint injections which produced 80% pain relief, each time lasting 
1-2 weeks.  
 
The requested RFA procedure is considered an experimental/ investigational procedure due to the wide 
variation in efficacy in the peer reviewed literature.  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 the RFA procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint nerves.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vyndamax. 
 
You asked the Plan to pre-approve Vyndamax. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee has a medical only policy which does not include Part D prescription 
coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
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 Vyndamax.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional trips 
due to not having a car and your medical conditions. The Plan denied your request. The Plan says your contract 
states that you only have 24 trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. The 25th trip and 
beyond is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve additional 
routine transportation trips.