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

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377).
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's upper limb strength and function are adequate to be able to control the power options using their own switches.
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 accessories. Our reviewer says that the requested accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the patient 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 patient 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 patient lives alone and is reported to need a power WC to complete ADLs. The patient smokes cigarettes. The 8/26/20 medical progress note states the patient denies weakness or tingling in arms or legs and has normal range of motion in the upper extremities. The documentation is conflicting on the patient's upper extremity function. The patient lives alone and needs the wheelchair for ADLs. There is no detailed exam of strength in the upper extremities and his functional ability is sufficient to control any power options through their own switches. 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6545.You asked the Plan to pre-approvethe compression stockings. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6545 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6545.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveKeytruda Solution 100MG/4ML (CPT Code J9271).You asked the Plan to pre-approvethe medication. You say that the medication is necessary.The Plan denied your request. The Plan says the enrollee does not meet the requirements for this medication.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 the medication. Our physician reviewer found per NCCN guidelines,keytruda, keytruda+chemo is indicated for EGFR non mutated cancer as this patient has a mutation. An EGFR inhibiter should be tried first.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 medication have not been met.Therefore, we decided that the Plan does not have to pre-approveKeytruda Solution 100MG/4ML (CPT Code J9271).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation with a periodontist.

You asked the Plan to pre-approve the consultation. You say that this is medically necessary.The Plan denied your request. The Plan says dental services performed by periodontist 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. The plan covers dental services when they are provided by a participating general dentist.

The requested provider type -periodontist -is not covered by the plan. Based on this information, we decided that the Plan's rules for coverage of the consultation have not been met.Therefore, we decided that the Plan does not have to pre-approve a consultation with a periodontist.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for the home health services provided from October 4, 2019, to November 25, 2019.
You asked the Plan to pay for the home health services. You say that you believe that payment should be made on this claim as both the RAP and the claim were submitted within the one-year time frame. The Plan denied your request. The Plan says that because the claim was not submitted within 120 days of the RAP, the RAP must be recouped, and the claim cannot be paid. The Plan must follow Medicare rules. Medicare rules say that the HH PPS payment methodology makes full payment on the claim when filed and reversed payment on the RAP. Review of the file does not support the rationale for denial of payment on the final claim for this episode of care. The Plan states that payment cannot be made on the claim because it was not filed within the appropriate time frame. However, the rules regarding the 120-day time frame apply only to the payment made under the RAP. Although it is correct that once 120 days elapse, the Plan is allowed to recoup the payment made on the RAP, this does not make the final claim unpayable. In this case, the Plan neglected to recoup payment when the 120-day time limit passed. The home health provider still has the standard one year to file a final claim. Although the plan is able to recoup payment for the RAP at any time after 120 days, doing so upon receipt of the final claim does not negate its obligation to make the payment on the final claim. In fact, as described above, when a final claim is received, it is already the standard to reverse RAP payment and provide the amount that is due based on actual utilization during the episode of care. It appears that in this case, the final claim amount is less than the RAP amount. The Plan is hence allowed to recoup only the difference between the RAP payment and the Medicare priced amount for the actual services rendered. It is not appropriate for the Plan to recoup the entire RAP payment and also deny payment on the claim. Therefore, we decided that the Plan has to pay for the home health services provided from October 4, 2019, to November 25, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment formyocardial perfusion imaging provided on July 31, 2020.You asked the Plan to waive the copayment forthe myocardial perfusion imaging. You say that this was just a Wellness Visit. The Plan denied your request. The Plan says you were charged this copayment 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 $25 copayment for Outpatient Diagnostic Tests. You have been asked to pay a $25 copayment for the myocardial perfusion imaging. The myocardial perfusion imaging falls within the Outpatient Diagnostic Tests 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 formyocardial perfusion imaging provided on July 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Contour Next Test Strips.You asked the Plan to pay forthe Contour Next Test Strips. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says there is no medically necessary reason for the member to use the non-preferred brand.The Plan follows Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers.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 Contour Next Test Strips. Our reviewer says that there is no medical indication for the continued use of the Contour strip. Our physician reviewer found there is no documentation that the member has tried and failed the now preferred brand.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 Contour Next Test Strips have not been met.Therefore, we decided that the Plan does not have to pay forthe Contour Next Test Strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the back brace (L0650), knee brace (L1833), suspension sleeve (L2397) and shoulder elbow wrist hand orthosis (L3960) provided on September 3, 2020.
You asked the Plan to pay for the orthoses. You say that you would like reconsideration because these supplies are medically necessary. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and provider.
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 the orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the lumbar-sacral orthosis is being prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible physical examination of the back. There is no documentation of recent injury to, or recent surgical procedure on, the enrollee's knee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. The documentation in the case file does not support that the requested shoulder/arm orthosis was medically reasonable and necessary for the enrollee in this case. A physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is insufficient documentation of a credible physical examination of the shoulder. 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 orthoses have not been met. Therefore, we decided that the Plan does not have to pay for the back brace (L0650), knee brace (L1833), suspension sleeve (L2397) and shoulder elbow wrist hand orthosis (L3960) provided on September 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided from April 29, 2019, through November 13, 2019, by an out-of-network provider.You asked the Plan to pay forthe medical services. You say that you called the health plan several times and no one informed you that the provider was no longer in-network.The Plan denied your request. The Plan says you called the health plan prior to services aware that your primary care provider had left the Plan and gone into private practice.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 had networkproviders available who could have provided 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 thatthe Plan does not have to pay forthe medical services provided from April 29, 2019, through November 13, 2019, by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe continuation of SNF care.You asked the Plan to pre-approvethe continuation of SNF care. You say that the requested continuation of SNF care is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested continuation of SNF care.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 continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the documentation does not support that skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse is required to safely and effectively provide medically necessary and reasonable treatment in a SNF after the last covered date. The enrollee does not have complex wound care or other SN needs that requires a SNF stay beyond the last covered date. 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 beyond the last covered date. Skilled services are not needed on a daily basis or as practical matter in a skilled nursing facility setting beyond the last covered date.
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 continuation of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approvethe continuation of SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora psychiatric diagnostic evaluation (90792) performed on March 7, 2019.You asked the Plan to pay fora psychiatric diagnostic evaluation. You say that these medically necessary services were provided to the enrollee in good faith and that you should not be penalized for delays in the receipt of information from the providing facility.The Plan denied your request. The Plan says rules for payment have not been met.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for a psychiatric diagnostic evaluation was not filed until September 8, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay fora psychiatric diagnostic evaluation (90792) performed on March 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued tumor treatment field therapy (TTFT).
You asked the Plan to pre-approve continued TTFT. You say that these services are medically necessary. The Plan denied your request. The Plan says that your request is not a covered benefit because records do not show that you were seen by the treating practitioner for a clinical re-evaluation between the 60th day and the 91st day after initiating therapy.
The Plan follows Medicare rules. Medicare rules say that continued TTFT is covered if the above criteria is 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 continued TTFT. Our reviewer says that continued TTFT is not medically reasonable and necessary. Coverage criteria under Medicare guidelines requires a clinical visit between the 60th day and the 91st day after initiating therapy (between November 8, 2020 and December 9, 2020). You were not seen during this time. Our physician reviewer found that you do not meet Medicare criteria for continued TTFT.
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 TTFT have not been met. Therefore, we decided that the Plan does not have to pre-approve continued tumor treatment field therapy (TTFT).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Lumbar Vertiflex Interspinous and/or interlaminar device (CPT Codes(s): 22869 and 22870).You asked the Plan to pre-approvethe services. You say that the services are necessary.The Plan denied your request. The Plan says the clinical value and effectiveness of the Vertiflex Superion Interspinous device in the setting of multi-level lumbar stenosis have not been demonstrated in the peer-reviewed literature.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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has at least moderate spinal stenosis at nearly all lumbar levels, and would not meet FDA indications. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is imaging evidence of scoliosis of the lumbar spine with no documentation of the Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated no osteoporosis in this patient. Superion indirect lumbar decompression would not be considered the standard of care for the enrollee's medical condition. Therefore, this request does not meet Medicare criteria as medically reasonable and necessary for treatment of this enrollee's medical condition.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-approvethe Lumbar Vertiflex Interspinous and/or interlaminar device (CPT Codes(s): 22869 and 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided by on November 14, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.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 physician's services. 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 physician's services providedon November 14, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services.You asked the Plan to pre-approvethe continued SNF services. You say that the records provided support the need for continued SNF care.The Plan denied your request. The Plan says the requested SNF care is not medically necessary and does not meet the 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 relevantMedicare rules to determine if the Plan was correct in denying the request to pre-approve the continued SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found, at the time of admission, the enrollee required skilled rehab services to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of January 31, 2021, the enrollee did not require any skilled nursing or rehab services on a daily basis.He was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care as of January 31, 2021. He did not have any parental medications, daily complex wound care or nutrition given via a feeding tube. The member received skilled care and improved; however,his function had plateaued by January 31, 2021, and he did notrequire any further inpatient skilled rehab services. The enrollee's function was at or near his maximal level of function and he could be discharged to a lower level of care for further services.As of January 31, 2021, the enrollee required custodial services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the continued SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services.