Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for advance care planning services (CPT 99497) provided to the enrollee on January 25, 2020.

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 Current Procedural Terminology (CPT) code 99497 remains not supported.

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 code 99497 is "Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate." 

We find that CPT code 99497 is not supported in the medical record. Specifically, the records indicate that this case was rendered on January 25, 2019, rather than the billed January 25, 2020. 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 advance care planning services (CPT 99497) provided to the enrollee on January 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexamethasone tab 4mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this request falls under Part D, and is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dexamethasone tab 4mg for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0481) provided to the enrollee on August 10, 2020.

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 Healthcare Common Procedure Coding System (HCPCS) code G0481 (1 Unit) remains not supported.

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 HCPCS code G0481 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 drug testing services (HCPCS G0481) provided to the enrollee on August 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown - porcelain fused to predominantly base metal (D2751) and core buildup, including any pins when required (D2950).

You asked the Plan to pre-approve a crown and core buildup. You say that you would like the services covered The Plan denied your request. The Plan says the services are not listed as covered under your dental benefit.

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. Therefore, we decided that the Plan does not have to pre-approve a crown - porcelain fused to predominantly base metal (D2751) and core buildup, including any pins when required (D2950).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen/pelvis.
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 CT scans are covered only when they are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was seen virtually with diarrhea and right lower quadrant pain for four to five days, as well as ear pain and scratchy throat. The request for an abdomen/pelvis CT was made to rule out colitis. Stool and blood work and a physical exam would be more appropriate to complete prior to a CT scan. There are no red flags to warrant the more urgent use of CT at this time. The services are 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 a computed tomography (CT) scan of the abdomen/pelvis.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Visudyne for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says a step therapy exception cannot be granted.
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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the plan requires a trial of Bevacizumab before they will approve the requested drug. In this case, the patient has not tried and failed this drug. There is no documentation provided indicating that the plan's required drug 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Visudyne for the enrollee.
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 LTACH would be the best option for this enrollee. The Plan denied your request. The Plan says the enrollee's needs can be met outside of the hospital setting.

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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says blood glucose is only tested twice per day.
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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are not taking three shots per day, and you are not adjusting your doses according to your blood glucose level. 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Brovana.
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 drug is not eligible for a tier exception.
The Plan must follow Medicare rules. Medicare rules say that Part B drugs are not eligible for Part D tier exceptions. We looked at the file and Medicare rules. The requested drug is covered under Part B Medicare and is not eligible for a Part D tier exception. 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 tier exception for Brovana.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tumor treatment field therapy for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says it is not considered medically necessary to continue use of this device if there is evidence of tumor progression.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee progressed while receiving tumor treatment field therapy and required resection. The enrollee did not demonstrate continued benefit from therapy. 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 tumor treatment field therapy for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery (CPT code 22869), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre 14-day sensor kit for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the information received from the prescriber does not support approval.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found there is a requirement for multiple insulin shots with daily adjustments of insulin dosage, based on blood
glucose levels in order to cover this monitor. The enrollee is not taking insulin now.
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 the Freestyle Libre 14-day sensor kit for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gradient compression stockings (A6531) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not have a venous stasis ulcer. There is no documentation of venous stasis ulcers or edema. The requested service cannot be recommended.

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 gradient compression stockings (A6531) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that you suffer from imbalances and have a history of falls. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).

You asked the Plan to pre-approve the spacer placement. You say that the spacer placement is medically necessary. The Plan denied your request. The Plan says the requested service is considered investigational and is not covered.

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 placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guidelines and peer-reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. 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

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 placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pravastatin Sodium 20 mg tablet.

You asked the Plan to pre-approve Pravastatin Sodium. You say that the enrollee is out of their medication.
The Plan denied your request. The Plan says this drug is not available under your medical benefit.

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 Pravastatin Sodium 20 mg
tablet.

Benefits for Pravastatin Sodium 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 20 skilled nursing home health visits (G0299) and 24
physical therapist home health visits (G0151) to be provided by an OON provider.

You asked the Plan to pre-approve 20 skilled nursing home health visits and 24 physical therapist home health
visits. You say that these services are medically necessary. The Plan denied your request. The Plan says there is
no evidence that these services are needed specifically from an OON provider.

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
20 skilled nursing home health visits (G0299) and 24 physical therapist home health visits (G0151) to be
provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic continuous glucose monitor sensors.

You asked the Plan to pay for therapeutic continuous glucose monitor sensors. You say that the enrollee needs
a therapeutic continuous glucose monitor to control diabetes. The Plan denied your request. The Plan says the
enrollee does not meet the criteria for a therapeutic continuous glucose monitor.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a therapeutic
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pay for
therapeutic continuous glucose monitor sensors.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (S9986).

You asked the Plan to pre-approve special supplemental benefits for the chronically ill. You say that the benefits are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that only services that are reasonable and necessary for the diagnosis or treatment of an illness or injury are covered. Medicare does not cover these services. The plan's rules apply in this case. The plan rules say that this benefit is only available for enrollees who have a qualifying condition. 

We looked at the file and Medicare rules. The documentation shows that the enrollee does not have one of the qualifying diagnoses, or that they are at high risk for hospitalization. Based on this information, we decided that Medicare rules for coverage of special supplemental benefits for the chronically ill have not been met. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (S9986).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cologuard testing provided on November 25, 2019 by an out of network (OON) provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The referring provider is not a network provider with the Plan. The Plan had network providers available who could have provided 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 Cologuard testing provided on November 25, 2019 by an out of network (OON) provider.