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

We decided that the Plan does not have to pre-approve Botox.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Botox is covered for specific indications only. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have a history of involuntary movement of the esophagus muscles (esophageal dyskinesia). The physician note dated December 17, 2019 states you have normal esophageal motor function. The assessment was that you were swallowing fairly well. The records do not show that you have a diagnosis or condition for which Botox is covered. Botox is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on August 16, 2019.
You asked the Plan to pay for the knee orthoses (L1833) and suspension sleeves (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says criteria was not 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 pay for the knee orthoses (L1833) and suspension sleeves (L2397). Our physician reviewer found the enrollee's chief complaint was right knee pain and left knee pain, documented in two separate notes on the same date of service. The documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, 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. 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 knee orthoses (L1833) and suspension sleeves (L2397) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on August 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic testing supplies provided from August 13, 2019 to November 1, 2019.
You asked the Plan to pay for the diabetic testing supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the delivery ticket and proof of delivery are missing required information.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file shows that the delivery ticket submitted did not include the carrier's tracking number. Also, the proof of delivery did not include an order number or details to corroborate the delivery ticket submitted. Therefore, we decided that the Plan does not have to pay for the diabetic testing supplies provided from August 13, 2019 to November 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has osteoporosis. There is no indication in the records that she has tried and failed, or is intolerant to, bisphosphonate therapy, including the plan's required zoledronic acid. Prolia is therefore not reasonable or medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve substance abuse treatment to be provided by out of network provider.
You asked the Plan to pre-approve substance abuse treatment. You say that there are no other doctors in the area that deal with Suboxone. The Plan denied your request. The Plan says there are in-network providers available.
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 pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available, a list was sent with the denial letter, 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 substance abuse treatment to be provided by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home monitoring/testing supplies (G0249) provided on April 15, 2019 through April 23, 2019.
You asked the Plan to pay for the supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim was billed more than the frequency allowance.
The Plan must follow Medicare rules. Medicare rules say that self-testing with the device should not occur more frequently than once a week. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. Specifically, 12 units of G0249 have been billed within a 3 week period. This exceeds the Medicare frequency allowance. Therefore, we decided that the Plan does not have to pay for home monitoring/testing supplies (G0249) provided on April 15, 2019 through April 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthrodesis services coded 22612 and 22614 provided on June 26, 2019.
You asked the Plan to pay for the arthrodesis 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 22612 is arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed). The CPT Code Manual definition of code 22614 is arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure). We find that CPT codes 22612 and 22614 are not supported in the medical record. Specifically, the medical records did not include documentation of a single level lumbar arthrodesis using posterior or posterolateral technique (with lateral transverse technique, when performed). Since the primary procedure code is denied, the add-on code 22614 is denied as well. Based on this information, we decided that Medicare rules for coverage of the arthrodesis services have not been met. Therefore, we decided that the Plan does not have to pay for the arthrodesis services coded 22612 and 22614 provided on June 26, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a hand x-ray (73120) provided on July 14, 2019.
You asked the Plan to pay for the hand x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that this service is not allowed when performed at this place of treatment.
The Plan must follow Medicare rules. Medicare rules say that If the physician/practitioner is aware of the exact setting where the beneficiary is a registered hospital outpatient, the appropriate outpatient facility POS code may be reported. We find that CPT code 73120 is supported in the record. Specifically, the imaging report corroborates that this service was rendered in the Emergency Department. The plan provided no citation that supports that radiology services cannot be paid when billed with POS code 23 which is contradicted by the official claim processing directions cited above. Based on this information, we decided that Medicare rules for coverage of the hand x-ray have been met. Therefore, we decided that the Plan has to pay for a hand x-ray (73120) provided on July 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tumor treatment field therapy (TTFT) for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that TTFT is covered for specific indications only. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a history of glioblastoma multiforme (GBM) and has had Optune TTFT in the past. The latest magnetic resonance imaging (MRI) shows recurrence in the right temporal lobe. The Medicare criteria state that TTFT is not covered for recurrent GBM. The services are therefore not reasonable and medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve tumor treatment field therapy (TTFT) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular diagnostic testing provided on July 17, 2019.
You asked the Plan to pay for the molecular diagnostic testing. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered
benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The molecular diagnostic testing at issue in this appeal was requested solely for screening purposes. Medicare
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay
for the molecular diagnostic testing provided on July 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan
denied your request. The Plan says the enrollee can receive the care required at the current facility they are in.
Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a
chronic obstructive pulmonary disease (COPD) exacerbation. Initially treated with bilevel positive airway
pressure (BiPAP), the enrollee was subsequently intubated, then extubated, then intubated again. The enrollee
has since received a tracheotomy. Anxiety and agitation are hindering weaning. It is unclear if or when these
issues will be under control. As LTACHs and ACHs are licensed to provide the same level of care, there is no
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for
any ongoing long term care (LTC) needs.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the transthoracic echocardiogram (TTE) rendered to you on August 9, 2019.
You asked the Plan to waive the deductible for these services. You say that there should be no cost share for the procedure. The Plan denied your request. The Plan says the deductible was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $975 yearly deductible for in-network and out-of-network Medicare-covered services. The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic radiology benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $975 yearly deductible for in-network and out-of-network Medicare-covered services. This cost sharing is a contractual obligation that had not been met at the time these services were received on August 9, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the transthoracic echocardiogram (TTE) rendered to you on August 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the OneTouch Verio Test Strip.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says it has other preferred meters and test strips, and there is no medical reason to use
a non-preferred brand.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found you have diabetes mellitus and check your finger stick blood glucose level once daily. The requested
strip is not a preferred strip by your plan. The reviewed documentation does not outline reasons the preferred
items cannot be utilized by the beneficiary. Without the support of the documentation, medical necessity cannot
be determined.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the OneTouch Verio Test Strip.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional medial branch blocks (64493).
You asked the Plan to pre-approve the medial branch blocks. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not indicate that member has tried medications, stretches or exercise for 3 months
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 medial branch blocks. 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 show that there has been an adequate trial of conservative therapy such as Chiropractic care or Physical Therapy. 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 medial branch blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve additional medial branch blocks (64493).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the member is not ready to be discharged home. The Plan denied your request. The Plan says the member does not meet Medicare requirements for IRF admission.The Plan must follow Medicare rules. The rulessay that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the member's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the member's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The member is at a functional level that does not require Physical or Occupational Therapieson an intensive rehabilitation facility therapy program level in an IRF.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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia for surgery of femur provided on June 13, 2019.You asked the Plan to pay forthe anesthesia. You say that the enrollee's hospice enrollment date was from September 11, 2018 through June 12, 2019. You also say that this date of service is outside ofthe enrollee's hospice stay date.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. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on June 12, 2019. The service in question was provided before the end of that month. Therefore, we decided that the Plan does not have to pay forthe anesthesia for surgery of femur provided on June 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says the enrollee is not stable and all necessary care can be provided in the
current facility indefinitely.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in
general, LTACHs do not provide clinical services that are materially different than those of short term acute
care hospitals. In this case, ongoing care needs include neurologic monitoring, surveillance laboratory studies,
tube feeding, wound care, and therapy services. The documentation does not support that the enrollee in this
case requires services at the LTACH that are not available at the acute care hospital where the enrollee is currently
receiving care. Consequently, the requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.