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

We decided that the Plan does not have to pre-approve Aranesp.
You asked the Plan to pre-approve Aranesp. You say that he records provided support the need for the drug being requested. The Plan denied your request. The Plan says there is no evidence that the enrollee has tried and failed Retacrit.
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 Aranesp. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee requires a trial of the drug Retacrit before they will approve the requested drug. The records do not show that the enrollee has tried and failed this required drug. The documentation does not support that Retacrit would likely be less effective 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 Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.
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 the records provided support the need for LTACH care. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer to an LTACH.
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 although admission to the current acute care hospital setting was required and mechanical ventilation was needed to support the acute exacerbation of COPD, recent records show improvement in weaning from BiPAP use. Recent signs of ongoing infection are still noted, and additional acute care is still needed at least for a short while, but not for more than 25 days based on the documentation provided. The enrollee does not require any additional services which might be available at the LTACH which are not already being provided and approved at the current facility. Therefore, this request for transfer to LTACH will be considered not medically necessary. Continuing care in the current facility is most appropriate until the enrollee is ready for a transfer to 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Granix.
You asked the Plan to pre-approve Granix. You say that the enrollee may reject the kidney he received if he does not get the requested medication. You say that the requested drug is medically necessary as the enrollee's blood count is low and he may need to remain hospitalized if the drug remains denied. The Plan denied your request. The Plan says the enrollee does not meet the standards for coverage of this drug. The Plan says that the enrollee does not have a covered condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Granix. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has documentation for one low white blood cell count at 2.4 on February 10, 2020 but no differential to show an absolute neutrophil count. The most recent clinical not provided on February 10, 2020 does not document recurrent infection. Granix is not FDA approved for treatment of a leukopenia without symptoms or supported by major drug compendia. The use of Granix in this enrollee is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Granix have not been met. Therefore, we decided that the Plan does not have to pre-approve Granix.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vertebral augmentation for the enrollee.
You asked the Plan to pre-approve the requested services. You say that the enrollee is in a terrible amount of pain. The Plan denied your request. The Plan says the enrollee should not have this procedure as he has more than 3 fractures that require treatment.
The Plan follows Medicare rules. Medicare rules say that Percutaneous Vertebral Augmentation is only covered under certain medical 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 the requested services. Our physician reviewer found that vertebroplasty is experimental. Recent studies show it is not more effective than sham treatment. 2 level vertebroplasty is not medically needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve vertebral augmentation 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 arthritis. You say that you need the requested chair to shower safely and that denying the chair lacks logic. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve life alert system.
You asked the Plan to pre-approve life alert system. You say that the home alert system is necessary because the enrollee is at risk for falling. The Plan denied your request. The Plan says this request is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Telephone alert systems are not covered because they are considered emergency communication systems and do not serve a diagnostic or therapeutic purpose. 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 life alert system.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee's ongoing stay in the inpatient rehabilitation facility is approved, and the transfer to a SNF is denied.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the patient does not meet criteria for coverage of SNF. The records do not support that the enrollee needs daily therapy. There are no noted daily skilled complex nursing needs. He is ambulating household distances and requires little assistance with mobility and transfers. While he may benefit from continuing therapy, the records do not support the need for daily 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Prodigy autocode meter kit for the enrollee.
You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that there is no medical reason for you to have this particular brand meter.
The Plan must follow Medicare rules. The rules say that the physician or treating practitioner must document in the beneficiary's medical record the reason why the specific brand or mode of delivery is necessary to avoid an adverse medical outcome. The only evidence in the case file shows that the Prodigy autocode meter kit is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve a Prodigy autocode meter kit for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement patient lift sling (E0621).
You asked the Plan to pre-approve replacement patient lift sling. You say that the sling you received in September is made of cotton and you want one that is synthetic for quicker drying time when it is washed. The Plan denied your request. The Plan says the records fails to show that the current lift sling received September 2019 has irreparable damage.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of replacement patient lift sling have not been met. Therefore, we decided that the Plan does not have to pre-approve replacement patient lift sling (E0621).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress.
You asked the Plan to pre-approve a powered pressure-reducing air mattress (E0277). You say that you do not have any pressure ulcers now however you want this mattress to prevent getting pressure ulcers. The Plan denied your request. The Plan says the Plan did not receive medical records to support medical necessity of the mattress.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a powered pressure-reducing air mattress (E0277) have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on March 7, 2019.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the provide is out-of-network. The services were not preauthorized or emergent.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the outpatient mental health services provided on March 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan from the skull base to mid-thigh (78815) provided on December 5, 2018.
You asked the Plan to waive the copayment for the PET CT scan from the skull base to mid-thigh. You say that you are being overcharged for the services you received. The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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% coinsurance for diagnostic radiology other than CT scans. You have been asked to pay $290.47 for the PET CT scan from the skull base to mid-thigh. 20% of $1452.35 (the allowed amount) equals $290.47. A PET CT scan from the skull base to mid-thigh falls within the diagnostic radiology other than CT scans 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 copayment for a positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan from the skull base to mid-thigh (78815) provided on December 5, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on September 17, 2019.
You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger. You say that this was a necessary service. The Plan denied your request. The Plan says payment of this service is included in the DRG payment.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on September 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on July 15, 2019.
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 are not covered.
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 G0482 is definitive drug testing, 15-21 drug classes. We find that CPT code G0482 is not supported in the medical record. Specifically, the records do not document that 15-21 drug classes were tested. 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 pay for the drug testing rendered to the enrollee on July 15, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on July 8, 2019.
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 claim was not billed with an appropriate diagnosis code.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The file shows that the claim for procedure code 99284 (ER services) was billed with diagnosis code Z00.00 (encounter for general examination without complaint, suspected or reported diagnosis). This diagnosis code is not appropriate for the services billed. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services rendered on July 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) provided on October 21, 2019.
You asked the Plan to reimburse you for the dental service. You say that the service you received should be covered under your Enhanced Dental package. You say that you paid $85 at the time you received the service because the office staff advised you did not have coverage. The Plan denied your request. The Plan says the frequency limit for oral exams has been exceeded. The Plan says that 2 oral exams are covered each year.
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 and oral exams are listed as a covered service, the frequency limit of 2 oral exams each year has been exceeded. The record shows that the Plan previously paid for oral exams that you received on January 16, 2019 and August 27, 2019. Therefore, we decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) provided on October 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ixempra (ixabepilone) and Lynparza (olaparib).
You asked the Plan to pre-approve Ixempra and Lynparza. You say that Ixempra and Lynparza are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for Medicare coverage of Ixempra and Lynparza.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Ixempra and Lynparza. Our reviewer says that Ixempra and Lynparza are not medically necessary at this time. Our physician reviewer found Ixabepilone is not a standard treatment in ovarian cancer and there are other standard therapies that the patient has not tried. There is no medical literature to support the combination of Ixempra (ixabepilone) and Lynparza (olaparib). The service is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ixempra and Lynparza have not been met. Therefore, we decided that the Plan does not have to pre-approve Ixempra (ixabepilone) and Lynparza (olaparib).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osteogenseis stimulator (E0747).
You asked the Plan to pre-approve osteogenseis stimulator. You say that the ordering physician has asked you to appeal the denial with the additional medical records and the published medical studies addressing the efficacy of your device. The Plan denied your request. The Plan says criteria is not met as the records do not show that the enrollee has had 3 months of treatment or an x-ray of the foot 3 months after the injury.
The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. In this case, nonunion of a long bone fracture is not considered to exist under Medicare rules. The file does not show that there were 2 or more serial radiographs separated by 90 or more days confirming that healing had ceased. Therefore, we decided that the Plan does not have to pre-approve osteogenseis stimulator (E0747).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmology office visit (92014) and refraction services (92015) provided on October 4, 2019.
You asked the Plan to pay for the vision services. You say that ever since you have been enrolled with the Plan this procedure has been covered. You have been billed for $129 and will not pay this charge until this appeal is resolved. The Plan denied your request. The Plan says the requested services are not a covered benefit of Medicare or the plan.
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 when only an exam and one pair of eyeglasses (or contact lenses) are covered for people after cataract surgery. We looked at the file and the Plan's rules. routine vision exam and refraction is not a covered benefit of the plan. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the ophthalmology office visit (92014) and refraction services (92015) provided on October 4, 2019.