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

We decided that the Plan does not have to pre-approv ea CardioMEMS device for the enrollee.

You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that a review of the current medical literature indicates that this service is considered experimental and investigational.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The patient was admitted with congestive heart failure recently and had an echo with ejection fraction equal to 35%. She was treated with intravenous diuretics and coronary revascularization/stenting in the hospital and became euvolemic and started on guideline directed medical therapy. She was reportedly euvolemic and symptomatically improved at discharge with plan to follow-up as outpatient. Cardiomems device therapy can play a role in management of complex heart failure patients where usual clinical signs and symptoms have failed to allow for adequate management of fluid status. However, the patient has now been started on aggressive guideline directed medical therapy and been revascularized during this admission, presumably with the hope for improvement of her left ventricle function of hibernating myocardium. There is no report of subsequent early decompensation with outpatient follow-up. Given the recently coronary revascularization, and now aggressive outpatient medical management and follow-up, consideration of Cardiomems implantation in the absence of failure of these therapies appears premature. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS device for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.

You asked the Plan to pre-approve the requested LDCT scan. You say that you would like reconsideration because this service is medically necessary.The Plan denied your request. The Plan says the member is outside the covered age parameters for this service.

The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above described criteria. 

We reviewed the file and the Medicare rules. We find that the member is 78 years old which is outside the covered age parameters described by the NCD.Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient physical therapy visits provided from January 11, 2021, to January 25, 2021.

You asked the Plan to waive the copayments for physical therapy visits. You say that you cannot afford to pay this copayment every time you go to physical therapy. The Plan denied your request. The Plan says the copayment amounts you are being charged are correct.

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 $35 copayment per day for in-network covered physical therapy. There were 5 visits, resulting in a total copayment obligation of $175.

You have been asked to pay $35 copayment for each physical therapy visit. Physical therapy visits fall within the Outpatient Rehabilitation Services 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 copayments for outpatient physical therapy visits provided from January 11, 2021, to January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stiolto Respimat.

You asked the Plan to pre-approve Stiolto Respimat. You say that you would like reconsideration because the member would benefit by starting a long-acting bronchodilator inhaled medication. The Plan denied your request. The Plan says this drug is not covered under 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 Stiolto Respimat.

Benefits for Stiolto Respimat 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 pay for the Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend provided on October 20, 2020.

You asked the Plan to pay for the Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend. You say that the Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend was medically necessary. The Plan denied your request. The Plan says the Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend was 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 pay for the Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend. Our reviewer says that the Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend was not medically necessary. Our physician reviewer found the member underwent treatment/therapy with a Sanexas neoGen-Series device for her low back pain. While this device is noted to have FDA 510(K) clearance for use, the device/technology is not readily supported within current medical literature for low back pain or neuropathic pain. This technology has not yet been critically evaluated in any well-designed clinical studies for the management of neuropathic pain.

The technology is not readily consistent with that used in the generally accepted standards of practice. Rather, given the limited peer reviewed literature available on this technology it would be better defined as being investigational in nature. In as much, the services under review would not have met/satisfied the Medicare definition of medical necessity.

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 Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend have not been met. Therefore, we decided that the Plan does not have to pay for the Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend provided on October 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the periodic oral evaluation (D0120) and the bitewing x-ray (D0274) from an out-of-network (OON) provider.

You asked the Plan to pay an additional amount for the oral evaluation and the bitewing x-ray. You say that the plan owes you an additional amount.The Plan denied your request. The Plan says you are responsible for each $10 copayment and balances over and above the plan's allowable charges.

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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested reimbursement for these services are in excess of those covered under this benefit.You are responsible for each $10 copayment, then any amount above the Plan's allowable amount charged by the out-of-network provider. Therefore, we decided that the Plan does not have to pay an additional amount for the periodic oral evaluation (D0120) and the bitewing x-ray (D0274) from an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the laboratory services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the laboratory services. You say that you would like reconsideration because the in-network labs do not have appointments in a reasonable time.The Plan denied your request. The Plan says medically necessary care is available within your network and there are no extenuating circumstances making it medically necessary to obtain the service out-of-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.Of note, the Plan has indicated that the in-network providers are taking appointments in a reasonable time frame. Therefore, we decided that the Plan does not have to pre-approve the laboratory services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services provided on August 26, 2020.

You asked the Plan to waive the copayment for the specialist services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a specialist office visit on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.

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 $35 copayment for each covered specialist office visit.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a specialist office visit on August 26, 2020. You have been asked to pay a $35 copayment for the specialist services. The specialist services fall within the Physician/Practitioner services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the specialist services provided on August 26, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided September 19, 2020 to
September 20, 2020.

You asked the Plan to pay for the acute inpatient hospital care. You say that the inpatient hospital services
provided from September 19, 2020 to September 20, 2020 was medically necessary. The Plan denied your
request. The Plan says that the inpatient hospital services provided from September 19, 2020 to September 20,
2020 was not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.

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 acute inpatient hospital care. Our
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our
physician reviewer found the history and physical assessment addresses the presenting issues of cirrhosis with
acute kidney injury from dehydration. The presenting MELD was at least 23 which is predictive of a 20%
three-month mortality. Admission anticipating spanning two midnights was documented. The treating
physician had a reasonable expectation of a length of stay spanning 2 or more midnights, taking into account
complex medical factors that was documented in the medical record. The fact the admission lasted less than
two midnights does not negate this expectation. The elements of the coverage decision are satisfied.

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 acute inpatient hospital care have been met. Therefore, we decided that the
Plan has to pay for the acute inpatient hospital care provided September 19, 2020 to September 20, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services (99601 and 99602) provided on July 9, 2020.

You asked the Plan to pay for the home infusion therapy services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says CPT codes 99601 and 99602 have a status indicator of I and are not valid for Medicare purposes.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT codes 99601 and 99602 are not supported in the record. Specifically, per the Physician Fee Schedule, CPT codes 99601 and 99602 have a status indicator of I. This means that these codes are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met.Therefore, we decided that the Plan does not have to pay for the home infusion therapy services (99601 and 99602) provided on July 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone/joint imaging, three phase study for the enrollee.

You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee already had an MRI, which is more useful to evaluate the tumor.

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 imaging. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee has already undergone an MRI that demonstrated a sclerotic lesion that had significantly enlarged but without bone marrow edema. The MRI report indicated correlation. with bone scan was suggested. There was no further information provided. Based upon the available documentation, the requested service is not medically reasonable or necessary as defined by Medicare rules. 

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 imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve bone/joint imaging, three phase study for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the anti-reflective lens coating (V2750) received November 10, 2020.

You asked the Plan to pay for the anti-reflective lens coating (V2750). You say that the Plan owes you more money.The Plan denied your request. The Plan says the total cost of the eye wear exceeds the $200 benefit allowance;therefore,you are responsible for any amount over $200.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to the $200 annual eye wear benefit allowance, applied to the retail value of covered items.

We looked at the file and the Plan's rules. The Plan submitted evidence that the $200 eye wear benefit allowance was applied to the retail value of claim on November 10, 2020. Therefore, the eye wear allowance was exhausted and you are responsible for any amount over the $200 billed by the provider. Based on this information, we decided that the claim processed correctly according to the Plan benefit.Therefore, we decided that the Plan does not have to pay for the anti-reflective lens coating (V2750) received November 10, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on August 12, 2020.

You asked the Plan to pay for the psychotherapy 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 services at issue. 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 psychotherapy services provided on August 12, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for molecular pathology testing (81210, 81235, 81275) provided July 29, 2020.

You asked the Plan to pay for molecular pathology testing. You say that the test results are considered an extension of the approved office visit for the appropriate continuity of patient care in the continued treatment of the enrollee's cancer diagnosis. The Plan denied your request. The Plan says that this service does not meet Medicare NCD/LCD criteria.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for molecular pathology testing. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found Molecular Diagnostic Studies in Non-Small Cell Lung Cancer (NSCLC) are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The NCCN NSCLC Guidelines Panel strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with NSCLC. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Molecular profiling is a standard of care for this patient with metastatic non-small cell lung to determine treatment options. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of molecular pathology testing have been met. Therefore, we decided that the Plan has to pay for molecular pathology testing (81210, 81235, 81275) provided July 29, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychotherapy services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve psychotherapy services. You say that you would like approval for these services to be provided out-of-network. The Plan denied your request. The Plan says there are in-network providers available for these services.

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 psychotherapy services to be provided by an out of network (OON) provider.