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

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your request. The Plan says a trial of Zoledronic Acid is required before alternatives like Prolia can be considered.
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 Prolia. Our reviewer says that rules for coverage have not been met. Our physician reviewer found there was no documented trial of the plan required alternative, or any record of why it would be contraindicated for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implantation of the LINX reflux management system coded as 43284.
You asked the Plan to pre-approve the LINX system. You say that this procedure is necessary to treat the enrollee's condition. The Plan denied your request. The Plan says there is not sufficient evidence to support that this service is reasonable and necessary for the treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that the MAC for the state of Pennsylvania has reviewed the literature and has not found reason to remove the non-coverage policy for the LINX procedure. Therefore, we decided that the Plan does not have to pre-approve the implantation of the LINX reflux management system coded as 43284.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 8, 2019.
You asked the Plan to pay for the laboratory services. 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 must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to payforthe hearing aids provided on November 16, 2019.You asked the Plan to pay forthe hearing aids. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the hearing aids were provided by an out-of-network provider and are not covered.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in thiscase. The Plan pays for hearing aids only when provided by a participating provider.We looked at the file and the Plan's rules. The file shows you received hearing aids provided by an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met.Therefore, we decided that the Plan does not have to pay forthe hearing aids provided on November 16, 2019.Your complaint about the Plan providing incorrect information is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orencia 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 there is no evidence of a trial of Simponia Aria. 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 there is no evidence of a trial and failure of Simponia Aria. The documentation does not support that Simponi Aria (Golimumab) 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Orencia for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 5, 2019.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that thePlan does not have to pay for subsequent nursing facility care provided on December 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc injections.
You asked the Plan to pre-approve Synvisc. You say that Synvisc is medically necessary. The Plan denied your
request. The Plan says a trial of Orthovisc and Monovisc is required before Synvisc can be considered.
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 Synvisc. Our reviewer says that
coverage criteria has not been met. Our physician reviewer found there was no trial of the plan preferred drugs
and no documented reason why they would be contraindicated.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have
to pre-approve Synvisc injections.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a laparoscopy with coloproctostomy (44207) provided on November 25, 2019.
You asked the Plan to pay for the laparoscopy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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 code 44207 is laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anastomosis). We asked our coder 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 laparoscopy. Our reviewer says that CPT code 44207 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation submitted does not support that a coloproctostomy was performed. 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 laparoscopy have not been met. Therefore, we decided that the Plan does not have to pay for a laparoscopy with coloproctostomy (44207) provided on November 25, 2019
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan has to waive the copayment for a colonoscopy providedon May 3, 2019.
You asked the Plan to waive the copayment for a colonoscopy. You say that this was a colonoscopy screening
and you disagree with the charges. The Plan denied your request. The Plan says that the claims were processed
correctly and the enrollee is being charged the correct amount.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not provide medical records. Without medical records we cannot
determine whether the colonoscopy was a screening or diagnostic. Therefore, we decided that the Plan has to
waive the copayment for a colonoscopy provided
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure coded 95999 provided on October 7, 2019.You asked the Plan to pay for the unlisted neurological or neuromuscular diagnostic procedure. 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 supported by the documentation.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 95999 is unlisted neurological or neuromuscular diagnostic procedure.We find that CPT code 95999 is not supported in the medical record. Specifically, the documentation shows that the enrollee had spinal surgery requiring neurophysiology monitoring. This service is considered a bundled procedure with the primary procedure. Therefore, separate payment for these services cannot be made. Based on this information, we decided that Medicare rules for coverage of the unlisted neurological or neuromuscular diagnostic procedure have not been met.Therefore, we decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure coded 95999 provided on October 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9500) provided on January 4, 2020 through January 10, 2020.You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because this is a payable code.The Plan denied your request. The Plan says CPT code S9500 has a status code of I which is not valid for Medicare purposes.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 S9500 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9500 has a status code of I. This means that CPT code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9500) provided on January 4, 2020 through January 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an adjacent tissue transfer (14040) and tendon repair (26433) provided on August 29, 2019.
You asked the Plan to pay for the tissue transfer and tendon repair. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does 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 code 14040 is adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less. The CPT Code Manual definition of code 26433 is repair of extensor tendon, distal insertion, primary or secondary; without graft (eg, mallet finger). We asked our coder 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 tissue transfer and tendon repair. Our reviewer says that CPT code 14040 does not meet criteria for billing or reimbursement consideration. The medical records submitted do not include documentation of an Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less being performed. Our reviewer found CPT code 26433 does not meet criteria for billing or reimbursement consideration. The medical records provided indicates that the "bony mallet was with pinning", which does not meet the code description of CPT 26433, therefore this service cannot be verified.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from December 6, 2019 through December 7, 2019.
You asked the Plan to pay for inpatient mental health 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 inpatient psychiatric services may be covered if the patient requires active treatment.
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 inpatient mental health care. Our physician reviewer found based upon review the records provided for the admission of this patient does not meet criteria for acute inpatient mental health treatment as she was not shown to be a danger to herself or others, no command auditory hallucinations or visual hallucinations. She is noted to be cooperative and compliant with treatment while not showing any aggressive behaviors. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from December 6, 2019 through December 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98942), electric stimulation therapy (97014), and hot or cold packs therapy (97010) rendered by the out of network provider from March 6, 2019 to July 31, 2019.

You asked the Plan to pay for these services. You say that you are requesting reconsideration of the plan's denial as the services should have been covered. The Plan denied your request. The Plan says the services were rendered by an out of network 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. Additionally, the only covered chiropractic service is manual manipulation of the spine to correct subluxation. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment (98942), electric stimulation therapy (97014), and hot or cold packs therapy (97010) rendered by the out of network provider from March 6, 2019 to July 31, 2019.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve an insertion of indwelling tunneled pleural catheter with cuff (32550). You asked the Plan to pre-approve an insertion of indwelling tunneled pleural catheter with cuff. You say that the services are necessary.The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan did not provide plan documentation or medical records. Without this documentation, the Plan denial is not substantiated and we must find in your favor.Therefore, we decided that the Plan has to pre-approve an insertion of indwelling tunneled pleural catheter with cuff (32550). 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair (K0001). You asked the Plan to pre-approve a manual wheelchair. You say that the requested item is needed. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. The Plan follows Medicare rules. Medicare rules say that a manual wheelchair for use inside the home is covered when specific criteria is met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a manual wheelchair. Our reviewer says that the item is not medically necessary. Our physician reviewer found the provided medical record does not possess the detail required to certify the necessity of the manual wheelchair. 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 manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair (K0001).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Vectra DA testing provided on December 4, 2019. You asked the Plan to pay for the Vectra DA testing. You say that this testing is covered by Medicare and cannot be denied. The Plan denied your request. The Plan says this is covered testing but this has already been covered twice in the past year. The Plan follows Medicare rules. Medicare rules say that Vectra DA testing is covered but should only be reimbursed twice per rolling 12-month period. 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 the Vectra DA testing. Our reviewer says that the documentation does not support the medical necessity of this testing being performed in excess of the frequency criteria. Our physician reviewer found the enrollee is a 63-year-old man with a diagnosis of Rheumatoid arthritis without rheumatoid factor, multiple sites. Vectra DA testing was ordered on 12/4/19. The plan denied coverage for this testing, stating that this service was previously paid for on 2/11/9 and 6/6/19. The documentation does not support that the Vectra DA testing on 12/4/19 was medically reasonable and necessary for the enrollee in this case. There are no clinical records in the case file to indicate that this testing was medically reasonable and necessary prior to the end of the rolling year in February 2020. 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 Vectra DA testing have not been met. Therefore, we decided that the Plan does not have to pay for the Vectra DA testing provided on December 4, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from July 11, 2019 through July 24, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from July 11, 2019 through July 24, 2019.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.