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

We decided that the Plan does not have to pre-approve Lucentis.

You asked the Plan to pre-approve Lucentis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.

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 Lucentis. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has a diagnosis of neovascular (wet) age-related macular degeneration. The documentation does not support that the enrollee has tried and failed bevacizumab. There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the 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 Lucentis have not been met. Therefore, we decided that the Plan does not have to pre-approve Lucentis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes coverage for certain dental item and services codes included in a dental benefits chart. This benefit does not include coverage for dental codes D2950 or D2740. You can find this information in Chapter 4 on pages 95 to 110 of the Plan's 2021 Evidence of Coverage (EOC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Lymphapress 4-chambered pneumatic compression device (E0651) and a pneumatic appliance (E0667) to be provided by an out-of-network provider.
You asked the Plan to pre-approve a Lymphapress 4-chambered pneumatic compression device and a pneumatic appliance. You say that the requested 4-chambered pneumatic compression device is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not been met.
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 provider at issue in this case is not a network provider with the Plan. 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 a Lymphapress 4-chambered pneumatic compression device and a pneumatic appliance. Our reviewer says that the requested out-of-network care for lymphedema treatment is not medically necessary in this case. Our physician reviewer found that the documentation does not demonstrate unique characteristics of the enrollee's condition that would necessitate a particular brand or supplier of a pneumatic compression device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Lymphapress 4-chambered pneumatic compression device and a pneumatic appliance have not been met. 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 a Lymphapress 4-chambered pneumatic compression device and a pneumatic appliance. Therefore, we decided that the Plan does not have to pre-approve a Lymphapress 4-chambered pneumatic compression device (E0651) and a pneumatic appliance (E0667) to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visit services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve office visit services to be provided by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the services requested are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network pain management specialists available to you that can provide the care and treatment you are requesting.
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 office visit 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 pay for the injections and contrast material provided on March 13, 2020.
You asked the Plan to pay for the injections and contrast material. You say that the billing software shows proof that the claim was originally submitted on time. You say that the claim should be reprocessed and payment should be issued. The Plan denied your request. The Plan says the time limit for filing has expired.
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 injections and contrast material was not filed until March 18, 2021. A claim is not considered filed until it is received by the payer. 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 injections and contrast material provided on March 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D2950, D2740, D0220, D0140, D0210, D0150) received January 6 and January 21, 2021 from the Medicare opt-out provider.
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for the requested services. The Plan denied your request. The Plan says the provider in this case has opted out of Original Medicare.
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 items or services are not among those covered under this benefit when received from a provider who has opted out of Original Medicare. The Plan has submitted evidence that the provider in this case was opted out of Original Medicare on these dates of services. Therefore, we decided that the Plan does not have to pay for the dental services (D2950, D2740, D0220, D0140, D0210, D0150) received January 6 and January 21, 2021 from the Medicare opt-out provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Quetiapine Tab 25mg (J8499).
You asked the Plan to pre-approve Quetiapine Tab 25mg. You say that the item is medically necessary. The Plan denied your request. The Plan says they do not cover self-administered drugs.
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 Quetiapine Tab 25mg (J8499).
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee could receive care in another setting.

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. Our
physician reviewer found the patient does not require treatment by multiple therapies and an intensive
rehabilitation therapy program. While the patient does require physical and occupational therapy, there is no
documented need for an intensive rehabilitation program. Medically necessary services can be provided in a
lower 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on September 8, 2020.

You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances. 

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided on September 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675).
You asked the Plan to pay for a pneumatic compression device. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules state that a PCD coded as E0675 to treat PAD is not eligible for reimbursement. A PCD coded as E0675 is used only for peripheral artery disease. Other PCD codes are not used for this condition. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide routine transportation trips with additional mileage.
You asked the Plan to provide additional mileage. You say that you need to see this doctor and the Plan-provided transportation is necessary to get you to your appointment. The Plan denied your request. The Plan says the routine transportation benefit can only cover up to 48 one-way trips of 50 miles per less per year. The trips you are requesting exceed this 50-mile limit and cannot be approved.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage.
For that reason, the Plan's coverage rules apply in this case. The Plan covers up to 48 one-way routine transportation trips when they are to or from Plan-approved locations and do not exceed 50 miles. We looked at your request, the records in the case file, and the rules. The location you are requesting is more than 50 miles away, and you are requesting two trips that exceed the Plan's 50-mile limit. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to provide routine transportation trips with additional mileage.
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 you would be confined to the hospital without rehab. The Plan denied your request. The Plan says you do not need to be seen by a rehab doctor at least 3 times a week.

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 you were admitted to the acute care hospital for weakness, a fall, and a urinary tract infection. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on September 8, 2020.
You asked the Plan to pay for a lumbar-sacral orthosis. You say that the requested item is a necessity for the enrollee's care. The Plan denied your request. The Plan says the requested item is 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 a lumbar-sacral orthosis. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible physical examination of the back. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on September 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a procedure and office visit (32550, 36598) provided March 10, 2021 to April 21, 2021.
You asked the Plan to waive the copayments for the procedure and office visit. You say that the copayments should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.
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 $225 copayment for outpatient surgical services and a $35 copayment for specialist visits. You have been asked to pay a $225 copayment and a $35 copayment for the procedure and office visit. the procedure falls under outpatient surgical services and the office visit falls within the specialist visits 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 a procedure and office visit (32550, 36598) provided March 10, 2021 to April 21, 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.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 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 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. Our physician reviewer found the documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee in this case requires at least 3 hours a day /5 days a week, or 15 hours over 7 consecutive days, of therapy 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 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 a vertiflex device (22870 and 22869).
You asked the Plan to pre-approve a vertiflex device. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is 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 pre-approve a vertiflex device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this service is experimental. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a vertiflex device have not been met. Specifically, there is insufficient evidence of the safety and efficacy of this service on the enrollee's diagnosis. This means the service is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve a vertiflex device (22870 and 22869).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (CPT 24343, CPT 24665) provided to the enrollee on January 7, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of the denied codes is: CPT 24343: repair lateral collateral ligament of the elbow with local tissue CPT 24665:Open treatment of radial head or neck fracture, includes internal fixation or radial head excision, when performed
We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the documentation submitted was reviewed and does not meet the criteria in this case. For CPT 24665, documentation supports a more specific code for arthroplasty elbow. Per the operative report, "After this was done, I then exposed the radial head. I removed the 2 pieces and sized it and sized to 22, was recreated it". For CPT 24343, documentation supports lateral ligament complex repair, and not collateral ligament repair. If documented correctly this code would be included with the Primary code of arthroplasty, elbow and not reported separately. Therefore, both CPT 24343 and CPT 24665 would not be covered. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (CPT 24343, CPT 24665) provided to the enrollee on January 7, 2021.