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

We decided that the Plan does not have to pre-approve the CardioMEMs device.
You asked the Plan to pre-approve the CardioMEMs device. You say that you would like reconsideration because the member had surgery last year and is still having issues in recovery. The Plan denied your request. The Plan says the requested service is 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 the CardioMEMs device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Food and Drug Administration has stated that the CardioMEMS HF System is indicated for wirelessly measuring and monitoring pulmonary artery (PA) pressure and heart rate in New York Heart Association (NYHA) Class III heart failure patients who have been hospitalized for heart failure in the previous year. The record does not support the presence of NYHA class III heart failure. The elements of the coverage criteria are not 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 CardioMEMs device have not been met. Therefore, we decided that the Plan does not have to pre-approve the CardioMEMs device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve these services. You say that the admission is not medically necessary. 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 care in a SNF when the four factors listed in the Medicare rules section 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you disagree with the denial.

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 skilled nursing facility (SNF) admission.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services you received on February 17, 2021.

You asked the Plan to waive the copayment for the ambulance services. You say that you were told this transport would be at no charge to you. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that there are no records showing you were advised no copayment would be due.

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 $280 copayment for ambulance services. 

You have been asked to pay a $280 copayment for the ambulance services. There is no provision in your contract for a waiver of this amount if you use specific ambulance companies or if the transport is between to affiliated facilities. 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 ambulance services you received on February 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the surgery you had at an ambulatory surgery center on February 17, 2021.
You asked the Plan to waive the copayment for the outpatient surgery. You say that you have had other surgeries in the past and have not had to pay a copayment. You said that you do not believe that copayments should be charged for surgeries. 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 $325 copayment for outpatient surgery. You have been asked to pay a $325 copayment for the outpatient surgery. 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 surgery you had at an ambulatory surgery center on February 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ambulance services provided from February 24, 2021, to March 10, 2021.
You asked the Plan to waive the copayments for ambulance services. You say that you were not consulted about the ambulance trips. 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 a $440 copayment for ambulance services. You received ambulance services from February 24, 2021, to March 10, 2021, for a total of 4 services. Therefore, you are responsible to pay the total amount of $1,7000.92, which is less than the total copayment
amount. You have been asked to pay the total copayment amount of $1,700.92 for ambulance services. Ambulance services fall within the ambulance 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 ambulance services provided from February 24, 2021, to March 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).

You asked the Plan to pre-approve the dental items. You say that the enrollee lost her dentures in 2020. The Plan denied your request. The Plan says complete dentures are covered once every 5 plan years. The Plan also says that the frequency limit for these items have been reached.

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 and dentures are listed as covered, the frequency limit has been reached. The record shows that the Plan paid for complete dentures that you received on December 19, 2019. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter rental.

You asked the Plan to pre-approve a power scooter rental. You say that you would like the Plan to reconsider their denial as the requested scooter rental is for the enrollee to use during an upcoming vacation. The Plan denied your request. The Plan says the requested durable medical equipment is not covered for primary use outside the home.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power scooter rental.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve scaling and root planing (D4342) for the upper right quadrant.

You asked the Plan to pre-approve the dental service. You say that this service should be covered. The Plan denied your request. The Plan says scaling and root planing is limited to once per quadrant every 2 plan years. The Plan also says that the frequency limit has been reached.

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 and scaling and root planing is listed as covered, the frequency limit has been reached. The record shows that the Plan paid for scaling and root planing for the upper right quadrant that you received on September 25, 2020. Therefore, we decided that the Plan does not have to pre-approve scaling and root planing (D4342) for the upper right quadrant.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on February 1, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with an inappropriate diagnosis code.

The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Specifically, the record shows that the claim was billed with diagnosis code R18.0. This code has a code first note, which means it is a manifestation code and must be sequenced after an etiology code. 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 pay for the services provided on February 1, 2021.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services she needs in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for weakness, pleural effusion and liver cancer. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on January 22, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not payable in the facility setting.

The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services provided on January 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for annual wellness visit, includes a PPS, subsequent visit (CPT code G0439) provided to the enrollee on April 14, 2020, by a non-participating provider.
You asked the Plan to pay for the annual wellness visit. You say that there is no previous Medicare wellness exam in the enrollee's chart. The Plan denied your request. The Plan says the limited service was exceeded.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The enrollee annual wellness visit (AWV) received an AWV subsequent visit, CPT code G0439, on February 12, 2020, from participating provider. Payment for this service was made on March 05, 2020. Per the above guidelines, denial of CPT code G0439 for April 14, 2020, is upheld as coverage for the AWV does not meet the Medicare requirements for service not being received within the past 12 months of a similar AWV service. If the provider determines that a billing error occurred during the initial submission of the denied claim, the plan would accept a submission of a corrected claim to consider services for payment. Therefore, we decided that the Plan does not have to pay for annual wellness visit, includes a PPS, subsequent visit (CPT code G0439) provided to the enrollee on April 14, 2020, by a non-participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty hospital bed.

You asked the Plan to pre-approve a heavy-duty hospital bed. You say that the requested hospital bed is medically necessary. The Plan denied your request. The Plan says you do not meet the weight requirement for the requested hospital bed.

The Plan must follow Medicare rules. Medicare has specific weight requirement for a heavy-duty hospital bed. Based on the medical records provided, you do not meet that criteria. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty hospital bed.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Neupogen (J1442).

You asked the Plan to pre-approve Neupogen. You say that the drug is medically necessary. The Plan denied your request. The Plan says that the drug is not medically necessary.

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 Neupogen. Our reviewer says that the drug is medically necessary. Our physician reviewer found there is documentation that use of Neupogen for myelodysplastic syndrome with neutropenia is supported by the major drug compendia and the documentation supports that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Neupogen have been met. Therefore, we decided that the Plan has to pre-approve Neupogen (J1442).

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 IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee requires intensive therapies to optimize mobility and strength. The Plan denied your request. The Plan says the enrollee is stable at home.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 physician reviewer found that the enrollee is experiencing dyspnea on exertion and will not be able to tolerate 3 hours a day of therapies in an IRF.

Documentation does not support the need for therapy program consisting of at least 3 hours of therapy per day at least 5 days per week. While she may benefit from physical and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. An IRF admission is not medically necessary based on lack of medical complexity and no identified skilled rehab nursing needs and her inability to tolerate 3 hours a day of therapies.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Interstim implantation.
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. Medicare rules say that Interstim implantation is covered when specific criteria are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has benign prostatic hyperplasia and underwent photovaporization of the prostate with greenlight laser in 2020. He has a hypotonic bladder and complains of incomplete emptying, intermittency, and nocturia. He underwent stage 1 Interstim on July 8, 2021. Results of that treatment with voiding diary were not provided. The criteria for coverage are not met and the Interstim is therefore 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 an Interstim implantation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate for use during an approved spinal fusion surgery.
You asked the Plan to pre-approve the bone marrow aspirate. You say that the services should be approved in full. The Plan denied your request. The Plan says all services aside from the use of bone marrow aspirate have been approved.
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 bone marrow aspirate. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental. More research is needed to show safety and efficacy of bone marrow aspirate as a bone graft extender material in spine surgery.
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 bone marrow aspirate have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate for use during an approved spinal fusion surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.
You asked the Plan to pre-approve the requested services. You say that radiofrequency ablation provided long-term pain relief in the past. The Plan denied your request. The Plan says the enrollee has not had dual facet injections with 80% pain relief.
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that the enrollee had worsening neck pain without radicular symptoms. A medial branch block was done with less than 80% neck relief lasting greater than 6 hours. The request is to forego the second medial branch block and proceed with radiofrequency ablation. diagnostic injections or MBBs at the same level as the previously successful RFA procedure are not medically necessary. The enrollee does not meet the criteria for this requested RFA 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.