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

We decided that the Plan does not have to pre-approve the drug combination Atezolizumab, Carboplatin, Paclitaxel, Bevacizumab with supporting drugs Dexamethasone, Fosaprepitant, Famotidine, Palonosetron, and Diphenhydramine for the enrollee.   You asked the Plan to pre-approve the requested drugs. You say that the enrollee experienced disease progression while on Keytruda. The Plan denied your request. The Plan says there are other medication combinations supported for second line treatment of non-small cell lung cancer.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested drugs. Our physician reviewer found that the enrollee has progression on 1st line therapy in multiple areas. Atezolizumab, Carboplatin, Paclitaxel, Bevacizumab with supporting drugs Dexamethasone, Fosaprepitant, Famotidine, Palonosetron, and Diphenhydramine is a first line therapy. Per the NCCN Guidelines if progression on PD-1/PD-LI inhibitor, switching to another PD-1/PD-L1 inhibitor is not recommended. This regimen would not be a standard 2nd line therapy as the enrollee is progressing on a 1st line therapy that already includes carboplatin and a PD-L1 inhibitor. Therefore, the service 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 the requested drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve the drug combination Atezolizumab, Carboplatin, Paclitaxel, Bevacizumab with supporting drugs Dexamethasone, Fosaprepitant, Famotidine, Palonosetron, and Diphenhydramine for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Spiriva 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 self-administered drugs are not covered.
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 Spiriva for the enrollee.  Benefits for these services 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis 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 self-administered drugs are not covered.
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 Eliquis the enrollee.
Benefits for these services 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 medical services provided on July 22, 2019 by the out of network provider.  You asked the Plan to pay for spirometry test. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.
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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on July 22, 2019 by the out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045) provided on February 16, 2019.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 71045, was denied because it is a column II procedure to the column I procedure, 71101.
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, we have confirmed that code the chest x-ray has a bundled relationship with code 71101 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71045) provided on February 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
You asked the Plan to pre-approve the compression stockings. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the compression stockings are not covered under Medicare.
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 the enrollee has open venous stasis ulcers or a qualifying wound. This means that the enrollee does 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-approve compression stockings identified with code A6545.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medication Procrit (J0885).
You asked the Plan to pre-approve this medication. You say that Procrit is medically necessary as the enrollee has chronic kidney disease. The Plan denied your request. The Plan says the requested drug is subject to step therapy. This requirement encourages you to try the preferred drug Retacrit, which is just as effective. Documentation was not received supporting a medical necessity step therapy exception.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 this medication. Our reviewer says that the enrollee does not meet the criteria for Procrit. Our physician reviewer found the patient has not tried and failed the required drug. The documentation provided does not support that Retacrit would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this medication have not been met. Therefore, we decided that the Plan does not have to pre-approve the medication Procrit (J0885).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty wheeled walker with seat.
You asked the Plan to pre-approve a heavy duty wheeled walker (E0149) with seat (E0159). You say that because of medical conditions the enrollee needs a heavy duty wheeled walker with seat. The Plan denied your request. The Plan says the enrollee does not weigh more than 300 pounds.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a heavy duty wheeled walker (E0149) with seat (E0159) have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty wheeled walker with seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you need a portable oxygen concentrator because you get out of breath when you walk around outside. The Plan denied your request. The Plan says oxygen equipment is covered for use inside the home and there are no reasons why lightweight portable oxygen tanks could not satisfy your needs within your 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. The record shows that you have a stationary oxygen system. This stationary oxygen system meets your in-home needs. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation (90792) provided on April 25, 2019.
You asked the Plan to pay for the psychiatric services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the GT modifier is not valid for this procedure code.
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 code 90792 is not supported in the record. Specifically, the use of a GT modifier is not appropriate for this procedure code. The use of modifier GT on professional claims has been eliminated. Use of the telehealth POS code 02 certifies that the service meets the telehealth requirements. Based on this information, we decided that Medicare rules for coverage of the psychiatric services have not been met. Therefore, we decided that the Plan does not have to pay for a psychiatric diagnostic evaluation (90792) provided on April 25, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One injections.
You asked the Plan to pre-approve the Synvisc-One. You say that this office does not carry either Orthovisc or Monovisc. The Plan denied your request. The Plan says the office can order the preferred drugs from the mail order pharmacy as these are the agents covered by the Plan.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Synvisc-One. Our reviewer says that the requested drug is not considered reasonable and necessary based on step therapy criteria. Our physician reviewer found the enrollee is an 88-year-old woman with a diagnosis of Unilateral primary osteoarthritis of the right knee. The enrollee has not tried the plan preferred drugs, Orthovisc or Monovisc. The documentation does not support that Orthovisc and Monovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 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 Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One injections.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on April 9, 2018.
You asked the Plan to pay for the ambulance services. You say that you would like the claim to be reprocessed and paid. The Plan denied your request. The Plan says that the claim was filed outside the allowable timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the ambulance services was not filed until September 17, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on April 9, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Venlafaxine extended-release capsules.
You asked the Plan to pre-approve self-administered drugs. You say that the enrollee has been treated with this medication since 2003 and stopping this medication would be a setback. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits. The Plan also says that the enrollee's commercial pharmacy benefits may be administered by the facility.
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 Venlafaxine extended-release capsules.
Benefits for self-administered drugs 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (CPT Code 99232) provided to the enrollee from February 11, 2019 through February 13, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says according to the ICD Manual, a secondary only diagnosis cannot be used as the primary, first-listed or principal diagnosis for any procedure or service.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The billed service, 99232, was denied because it did not include the appropriate primary, first-listed or principal diagnosis, per policy, which is based on the ICD Manual. The secondary only diagnosis cannot be used as the primary, first-listed or principal diagnosis for any procedure or service. Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. Wherever such a combination exists, there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. If you look up the definition of the principal code it includes a note which says "code first" underlying physiological issue. This means that F05 is not an appropriate main diagnosis code because the cause of the diagnosis described by F05 should be coded first. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (CPT Code 99232) provided to the enrollee from February 11, 2019 through February 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 you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 documentation does not support that the enrollee requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no required medical services that are available at the LTACH but not available at the current health care setting being offered by the Plan. 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.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve the SNF admission. You say that you are requesting the decision to deny be reversed and the coverage be extended. The Plan denied your request. The Plan says the enrollee does not meet medical necessity criteria for skilled nursing facility.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does have skilled therapy service needs but does not require skilled therapy on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the observation services provided on July 24, 2019.
You asked the Plan to waive the coinsurance for the observation services. You say that you were not charged for your previous admission. You say you should not be charged now. The Plan denied your request. The Plan says you have been charged the correct cost 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 20% coinsurance for each outpatient hospital and observation services. You have been asked to pay total of $548.88 which is 20% the allowed amount for the observation services. The allowed amount is $2,744.42. ($2,744.42 x 20% = $548.88). The observation services fall within the "Outpatient hospital 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 coinsurance for the observation services provided on July 24, 2019.
Our decision is only about the 2019 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from December 17, 2019
through discharge.
You asked the Plan to pay for SNF care. You say that the stay was medically necessary. The Plan denied your
request. The Plan says the stay 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 pay for SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found based on available records, the patient does
not meet criteria for coverage of SNF. The records do not support that the enrollee needs daily physical therapy
(PT) and occupational therapy (OT). There are no noted daily skilled complex nursing needs. While she may
benefit from continuing PT and OT, the records do not support the need for daily therapy. Her needs are
custodial in nature.
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 care have not been met. Therefore, we decided that the Plan does not have
to pay for SNF care provided to the enrollee from December 17, 2019 through discharge.