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

We decided that the Plan does not have to pre-approvecompression wrap identified with code A6545.You asked the Plan to pre-approvethecompression wrap. You say that you are appealing because you are receiving treatment for lymphedema with physical therapy and the compression wrap is being requested for control it.The Plan denied your request. The Plan says this item is not covered under Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approvecompression wrap identified with code A6545.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for DermTech Pigmented Lesion Assay (PLA) testing provided on December 4, 2019.You asked the Plan to pay for genetic testing. You say that this testing was not screening and was deemed medically necessary by the enrollee's treating physician.The Plan denied your request. The Plan says that the denial of payment for these services is correct, because these tests are experimental/investigational and were performed for screening purposes.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered.Without this information, we cannot determine whether this lab order constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this claim is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay forDermTech Pigmented Lesion Assay (PLA) testing provided on December 4, 2019.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-approveincontinence supplies, incontinent garments/diapers (A4520) and wipes (A9270).You asked the Plan to pre-approveincontinence supplies. You say that you had a intestinal bypass in 1977 which left you with chronic diarrhea. You have to change your pad and women's breif's 7-10 times per day. You are housebound and this is leading to other issues.The Plan denied your request. The Plan says this item is not covered.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approveincontinence supplies, incontinent garments/diapers (A4520) and wipes (A9270).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the total electric hospital bed with rails and mattress.You asked the Plan to pre-approve the total electric hospital bed with rails and mattress. You say that you request reconsideration of the denial and the records should support the necessity of the requested item.The Plan denied your request. The Plan says this item is not covered under Medicare or the plan.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriatein this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approve the total electric hospital bed with rails and mattress.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee had stable vital signs. The enrollee received oral medications. The enrollee required modified independence to supervision/stand-by assistance with functional mobility including walking to 250 feet with a rolling walker. The enrollee required supervisor with activities of daily living.The documentation does not support that the enrollee requires the specialized skills, knowledge, or judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, at a SNF level of care. 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 admission have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe retainer crown for tooth #'s 23-25.You asked the Plan to pre-approvethe retainer crown. You say that the enrollee has difficulty eating and it is affecting his health.The Plan denied your request. The Plan says bridges (excluding third molars) are covered to replace one (1) upper front tooth or two (2) adjacent lower front teeth and there cannot be any missing back teeth.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 the retainer crown when the services are medically necessary and reasonable. 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 retainer crown. Our reviewer says that the criteria for coverage has not been met. Our physician reviewer found there is no necessity for the requested procedure as there are missing posterior teeth.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the retainer crown have not been met.Therefore, we decided that the Plan does not have to pre-approvethe retainer crown for tooth #'s 23-25.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cyclobenzaprine.You asked the Plan to pre-approve the Cyclobenzaprine. You say that the enrollee has been on Cyclobenzaprine since August of 2015 and has had good results. You also say that the enrollee tried over the counter medicines, but they did not help.The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered 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 Cyclobenzaprine. Benefits for Cyclobenzaprine may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvephysician services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvephysician services. You say that you would like authorization for these services.The Plan denied your request. The Plan saysthese services can be provided in-network.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-approvephysician services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora Medicare Part B drug provided on March 3, 2020.You asked the Plan to waive the coinsurance fora Medicare Part B drug. You say that you were never informed that you would owe additional charges for the injection.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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on March 3, 2020. The allowed amount is $144.69 and 20% of that is $28.94.You have been asked to pay the total coinsurance amount of $28.94 for a Medicare Part B drug. A Medicare PartB drug falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance fora Medicare Part B drug provided on March 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe laboratory services provided on March 6, 2020and March 10, 2020.You asked the Plan to waive the copayment forthe laboratory services. You say that these amounts are causing hardship for you.The Plan denied your request. The Plan says the claim has been processed correctly per your plan benefits.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 $45 copayment for lab services. You have been asked to pay a $45 copayment for the laboratory services. the laboratory services fall within the outpatient hospital 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 forthe laboratory services provided on March 6, 2020 and March 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the arthrocentesis and the Part B injection provided on March 18, 2020.You asked the Plan to waive the cost share for the arthrocentesis and the Part B injection. You say that you were not told there would be a separate cost share for the injection.The Plan denied your request. The Plan says you have been charged the correctcost sharing 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 $20 copaymentper visit to a specialist and 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a total of $48.94 for the arthrocentesis and the Part B injection. The arthrocentesis falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Part B injection falls within the "Medicare Part B prescription drugs" benefit category. See chart below. 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 cost share for the arthrocentesis and the Part B injection provided on March 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says this drug is 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 Keytruda. Our reviewer says that
Keytruda is not medically reasonable and necessary for the enrollee in this case. Our physician reviewer found
that Keytruda is FDA approved for the treatment of recurrent locally advanced or metastatic squamous cell
carcinoma of the esophagus in patients whose tumors express PD-L1 as determined by an approved test, with
disease progression after one or more prior lines of systemic therapy. This enrollee has an adenocarcinoma of
the esophagus and no PD-L1 testing is provided. Even if considered a gastroesophageal tumor there is not PDL1
testing and the enrollee is HER2 positive. In addition, there is no MSI or MMR testing to support the use of
immunotherapy via molecular profiling. Off-label use is not supported by major drug compendia or the medical
literature.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically
necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 a 61-year-old female who was admitted and treated with diverting
colostomy, sacral ulcer excision with coccygectomy, rotational flap placement, antibiotics, wound
debridement, and basic wound care. She was switched from IV antibiotics to oral antibiotics, and there are no
planned wound procedures or complex treatment/monitoring needs for the wound. She still has a JP drain and a
diverting colostomy which requires monitoring along with her new flap. The enrollee appears to require a short
amount of additional acute care services to allow for continued improvement until stable for discharge to a
lower level of care. The enrollee does not require services at the LTACH that are not already available at the
current acute care hospital. The enrollee appears to be improving enough to expect the current acute care
hospital stay to be less than 25 days. There are no services available at the LTACH that the enrollee requires
that are not already being received or available and covered at the current facility. There is no advantage to
transferring the enrollee at this time. Therefore, this request for LTACH services will be considered 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 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 for the enrollee.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for oncology (urothelial) gene expression profile testing provided on February 27, 2020.
You asked the Plan to pay for genetic test. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this test is investigational and prior authorization was not obtained.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Although the Plan claims that prior authorization is required for genetic testing, the Evidence of Coverage (EOC) does not clearly state this. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan did not show that its decision to deny payment for this test is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay for oncology (urothelial) gene expression profile testing provided on February 27, 2020.
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: 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 IRF admission is medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria are not met.
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 preapprove
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 your nursing,
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary
approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing
oversight only in an IRF. The documentation does not support that your functional level requires intensive
rehabilitation therapy program provided 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95937) provided on March 6, 2020.
You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration because the service rendered was medically necessary. The Plan denied your request. The Plan says it is not appropriate to bill separately for train of four monitoring.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that all services integral to accomplishing a procedure are considered bundled into that procedure and, therefore, are considered a component part of the comprehensive code. In this case, the CPT Code Manual definition of code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. We find that CPT code 95937 is not supported in the record. Specifically, train of four monitoring is integral to the primary neuromonitoring service and no separate payment may be made. Based on this information, we decided that Medicare rules for coverage of the train of four monitoring have not been met. Therefore, we decided that the Plan does not have to pay for train of four monitoring (95937) provided on March 6, 2020.