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

We decided that the Plan does not have to pre-approve Dupixent.

You asked the Plan to pre-approve Dupixent. You say that this is medically necessary and has benefited the enrollee. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.

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 Dupixent.

Benefits for Dupixent 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the diagnostic testing provided on April 24, 2020.

You asked the Plan to waive the coinsurance for the diagnostic testing. You say that you do not owe any copayments. The Plan denied your request. The Plan says you were charged the copayments 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 $20 copayment for non-radiological diagnostic services and a $150 copayment for radiological diagnostic services. 

You have been asked to pay a $20 copayment for non-radiological diagnostic services and a $82.13 copayment, which is less than the required copayment, for radiological diagnostic services. The diagnostic testing falls within the Outpatient Diagnostic Tests 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 diagnostic testing provided on April 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the prostate biopsy provided on January 21,
2020.

You asked the Plan to waive the copayment for the prostate biopsy. You say that you didn't receive a bill for
the previous test. You say that you were not informed you would be responsible for a $295 copayment. The
Plan denied your request. The Plan says the copayment applied 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 $295
copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital,
including but not limited to hospital or other facility charges and physician or surgical charges.

You have been asked to pay a $295 for the prostate biopsy. The prostate biopsy falls within the "Outpatient
Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical
Centers" benefit category. The prostate biopsy is considered a surgical procedure.

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 prostate biopsy provided on January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injections of lower or sacral spine facet joint using imaging guidance (CPT Codes: 64493 and 64494).

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says this injection can be done when the member's pain is present only in their back. The Plan states the member should not have pain, numbness, or weakness in their leg and the member's records tell the Plan that the they have pain elsewhere.

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 services. Our physician reviewer found the requested procedure is supported for predominantly axial pain that is not associated with radiculopathy or neurogenic claudication. The office notes indicate the patient has chronic low back pain with radiation. The provided diagnosis is M47.27 - Other spondylosis with radiculopathy, lumbosacral region. The patient does not meet all the criteria for coverage in L34892 for the facet joint intervention. Therefore, the requested injections are not medically reasonable and necessary to treat 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve injections of lower or sacral spine facet joint using imaging guidance (CPT Codes: 64493 and 64494).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9338 provided on July 22, 2020.

You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

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 S9338 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting, and payment of these services. 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 coded S9338 provided on July 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer device.

You asked the Plan to pre-approve the spacer device. The Plan denied your request. The Plan says this 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 the spacer device. Our reviewer says
that the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found that there is a lack of large volume, long-term peer-reviewed outcome studies to support the use
of this device for this enrollee's medical condition as discussed above. There is no discussion relative to why
this enrollee would not be indicated for standard decompression surgery. FDA indications include implantation
of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom
operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has mild central and
bilateral neuroforaminal stenosis at the L3/4, and would not meet FDA indications. A lumbar MRI report is not
submitted to support spinal stenosis of a moderate degree at any level. FDA contraindications include
osteoporosis, that has not been adequately addressed in the medical records. There is no discussion indicating
that a DEXA scan has demonstrated no osteoporosis in this post-menopausal 73-year-old female. Superion
indirect lumbar decompression would not be considered the standard of care for the enrollee's medical
condition.

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 spacer device have not been met. Therefore, we decided that the Plan does
not have to pre-approve a Superion interspinous spacer device.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a tertiary care follow-up visit.

You asked the Plan to pre-approve the tertiary care visit. The Plan denied your request. The Plan says that it is not medically necessary for the enrollee to see a tertiary care provider.

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 pre-approve the tertiary care visit. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee presents with right knee pain with associated swelling and malalignment. Significant functional limitations are noted. She has a diagnosis of osteogenesis imperfecta. Clinical exam findings are consistent with radiographic evidence of significant worsening of degenerative changes (particularly involving the lateral compartment) with increasing valgus angulation of the knee. In this case, tertiary level consultation regarding joint replacement surgery is indicated based on the unique circumstances and surgical challenges of performing total knee replacement in patients with osteogenesis imperfecta. Therefore, the requested tertiary care services at issue in this case are medically reasonable and necessary over the plan-approved non-tertiary 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 the tertiary care visit have been met. Therefore, we decided that the Plan has to pre-approve a tertiary care follow-up visit.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Kyphoplasty (22513, 22515).

You asked the Plan to pre-approve Kyphoplasty. You say that the enrollee has painful fractures. The Plan denied your request. The Plan says the enrollee does not have vertebral fractures.

The Plan follows Medicare rules. Medicare rules say that Percutaneous vertebroplasty and percutaneous vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and necessary for the above 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 Kyphoplasty. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found there is no documentation of a recent fracture less than 6 weeks old. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Kyphoplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve Kyphoplasty (22513, 22515).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power seat elevation system, any type (CPT Code E2300).

You asked the Plan to pre-approve the power seat elevation system. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve power seat elevation system, any type (CPT Code E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyoPro limb orthosis (CPT Code L8702) to be
provided at the in-network benefit level with an out-of-network provider.

You asked the Plan to pre-approve the orthosis. You say that the orthosis is necessary. The Plan denied your
request. The Plan says medical studies haven't proven that the device(s) is helpful for treatment of the member's
health problem.

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 orthosis. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the review has determined that a review of the literature indicates that the clinical value and
effectiveness of MyoPro myoelectric arm orthotic in the setting of cerebrovascular accident (CVA) has not
been demonstrated. There is no specific clinical rationale for the requested item. The review has determined
that the items/services at issue in this case are not medically reasonable or 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve
MyoPro limb orthosis (CPT Code L8702) to be provided at the in-network benefit level with an out-of-network
provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health care services provided from September 9,
2019, to October 19, 2019.

You asked the Plan to pay for the home health care services. You say that you would like these services
covered by the Plan. The Plan denied your request. The Plan says the provider is not certified for Medicare.

The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare
program

We looked at the file and Medicare rules. The file indicates that the home health agency used is not eligible for
payment by Medicare. Based on this information, we decided that Medicare rules for coverage of the home
health care services have not been met. Therefore, we decided that the Plan does not have to pay for the home
health care services provided from September 9, 2019, to October 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ensure high protein for six (6) months.

You asked the Plan to pre-approve the services. You say that you were sick and could not eat. You state you
are under 100 pounds and need the Ensure to build muscle. The Plan denied your request. The Plan says the
Medicare rules have not been met.

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 notes we have say this
supplement will be given to your orally. The Plan nor Medicare pay for this type of supplement or related
supplies, if they are given orally. Therefore, we decided that the Plan does not have to pre-approve Ensure high
protein for six (6) months.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (CPT Code 22869).
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says the member is not enrolled in a clinical study.
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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy. 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (CPT Code 22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the ophthalmological exam and refractive services (S0620, 92015) and new progressive lenses and deluxe frames (V2781, V2025) provided on February 26, 2020 to March 11, 2020.
You asked the Plan to reimburse you for the ophthalmological exam and refractive services and new lenses and frames. You say that the services should be covered. The Plan denied your request. The Plan says the claims processed correctly.
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 by providing you with a $300 benefit for eyeglasses. We looked at the file and the Plan's rules. Regarding the ophthalmological exam, you were not charged a copayment. Regarding the eyeglasses, the total for services received was greater than the $300 benefit and you were charged the retail price on top of the benefit. It appears that the claim processed correctly for your supplemental benefit. Therefore, we decided that the Plan does not have to reimburse you for the ophthalmological exam and refractive services (S0620, 92015) and new progressive lenses and deluxe frames (V2781, V2025) provided on February 26, 2020 to March 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram provided on February 4, 2020.
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that all of your mammograms have been fully covered. The Plan denied your request. The Plan says the copayment applied 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 $75 copayment for all other diagnostic procedures and tests at all locations of service. You have been asked to pay a $75 copayment for the diagnostic mammogram. The diagnostic mammogram falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the mammogram was ordered for diagnostic purposes. 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 diagnostic mammogram provided on February 4, 2020.
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 acute rehab for her prosthetic
gait. The Plan denied your request. The Plan says the enrollee's needs are not complex, and there is no need for
an intensive team for care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found
that the enrollee was admitted to the acute hospital for a right above the knee amputation. Her medical
problems are stable. The complexity of the enrollee's nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical record
supports a need for physical and occupational therapy, but it does not support a need for an intensive
rehabilitation therapy program.
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: 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 this request allows the enrollee the
highest potential level of function for recovery. The Plan denied your request. The Plan says the enrollee is
receiving appropriate inpatient acute care, and does not require transfer.
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 physician
reviewer found that the enrollee was admitted to the current acute care hospital with shortness of breath and
weakness related to COVID-19 pneumonia with sepsis. He required oxygen supplementation, steroids,
convalescent plasma, and Remdesivir. He is currently still requiring oxygen supplementation, but is gradually
weaning. The enrollee appears to be requiring additional short term acute care services, however, he can safely
receive this care at the current facility. The enrollee does not require services at the LTACH that are not already
available at the current facility. Therefore, this request for LTACH services will be considered not medically
necessary 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.