Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on February 27, 2020 by an out of network (OON) provider.You asked the Plan to pay forphysician services. You say that you are the member's primary care physician.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the primary care physician on file is not the same as the rendering physician.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 forphysician services provided on February 27, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found 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 enrollee was admitted for evaluation of tremors and lower extremity weakness. Physical therapy evaluation recommended treatment 1-5 times per week. All chronic medical problems are stable. There are no complex nursing medical or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. Although there is a documented need for physical therapy services, there is no documentation of a need for intensive rehabilitation therapy. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Orthovisc injection (J7324).
You asked the Plan to pre-approve Orthovisc. You say that Orthovisc is medically necessary. The Plan denied your request. The Plan says the injection is not medically necessary.
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 Orthovisc. Our reviewer says that Orthovisc is not medically necessary. Our physician reviewer found the effectiveness of repeat courses of Orthovisc has not been established. As the enrollee has already received Orthovisc to his left knee, a repeat course is not indicated. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve an Orthovisc injection (J7324).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core buildup, including any pins when required
(D2950).
You asked the Plan to pre-approve the core buildup. You say that you are unable to afford this service. The
Plan denied your request. The Plan says this is not a covered service.
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 the
core buildup, including any pins when required (D2950).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
You asked the Plan to pre-approve continued SNF care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continuation SNF care.
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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted for a short term rehab on 7/24/20 from an acute facility where she was treated for ambulation issues. She was admitted to acute care on 7/23/20 as she was unable to walk due to lower extremity edema from congestive heart failure. She was treated and transferred to SNF. In the hospital on 7/23/20 she walked 50 feet with contact guard assist and walker. Based on review of available records, the enrollee does not meet criteria for coverage for continued care at SNF. She has no nursing needs or therapy needs as an inpatient requiring therapies on a daily basis based on medical stability and functional status.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient mental health treatment.You asked the Plan to pre-approveinpatient mental health treatment. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 inpatient mental health treatment. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based upon review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment facility beyond the date in question of July 24, 2020 forward. The enrollee could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visualhallucinations, delusions and was not showing any behaviors or aggression. The enrollee was being cooperative and compliant while not showing any acute threats to safety.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 treatment have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient mental health treatment.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.
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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Padcev and Granisetron Hydrochloride for the enrollee.
You asked the Plan to pre-approve Padcev and Granisetron Hydrochloride. You say that this treatment is reasonable and appropriate for the enrollee. The Plan denied your request. The Plan says that this is not supported.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Padcev and Granisetron Hydrochloride. Our reviewer says that Padcev and Granisetron Hydrochloride are not medically reasonable and necessary for the enrollee in this case. These drugs are being requested to treat the enrollee's metastatic bladder cancer. You state that the enrollee does not want systemic chemotherapy. Padcev is not FDA approved for first line therapy. None of the CMS approved compendia support the requested use. There are not supporting citations in a PubMed search. The use is not listed as not indicated, not recommended or not supported in any of the compendia. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for Padcev and Granisetron Hydrochloride. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Padcev and Granisetron Hydrochloride have not been met. Therefore, we decided that the Plan does not have to pre-approve Padcev and Granisetron Hydrochloride for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a hammer toe correction (28285).
You asked the Plan to pre-approve a hammer toe correction. You say that this is medically necessary. The Plan
denied your request. The Plan says that the records do not show the enrollee has tried conservative treatment.
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 a hammer toe correction. Our reviewer
says that the requested services are considered medically reasonable and necessary in this case. Our physician
reviewer found it is well documented in the medical progress note that this patient is suffering with a painful
contracted fifth toe right side. Patient has attempted conservative treatments including shoe gear modification
and trimming of painful callous, without resolution of pain. Physical examination demonstrates a
malformation/hammertoe deformity of the fifth toe right side. X-rays confirmed this malformation with
confirmation of calcification of the head of the proximal phalanx fifth toe right side.
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 hammer toe correction have been met. Therefore, we decided that the Plan has
to pre-approve a hammer toe correction (28285).
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.You asked the Plan to pre-approve Prolia. You say that this is necessary for the enrollee's condition.The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage.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 Prolia. Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee in this case. The enrollee sustained a hip fracture resulting from a fall. A DEXA scan completed in 2017 was noted to have bone density within normal limits. The records do not support a diagnosis and therefore, the requirement of the requested medication. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Prolia.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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #29.
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says there is not
sufficient documentation to support the porcelain-fused-to-metal crown for tooth #29.
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. The Plan covers the crown
when the services are medically necessary and reasonable.
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 crown. Our reviewer says that the
service is not medically necessary. Our physician reviewer found the x-rays show a defective distal margin on
tooth #29. The remaining arch needs to be assessed to be able to determine if replacing the single unit of tooth
#29 is reasonable. It is unclear if #29 is critical to the remaining sectioned bridge or not. Our reviewer found
that a full set of x-rays would be needed to assess how reasonable it would be to replace tooth #29 as a single
unit. Our physician reviewer also found that if it can be shown that tooth #29 would not reasonably be needed
in the next five years to help support the remaining bridge, or if in fact the remainder of the bridge can be
replaced as single units, then a single unit crown can be considered.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have
to pre-approve a crown (D2740) for tooth #29.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).You asked the Plan to pre-approve the complete maxillary and mandibular dentures. You say that your dentures were lost or stolen. You also say that you are having a hard time eating, and your gums are in a lot of pain.The Plan denied your request. The Plan says these services exceed the maximum count allowed per period.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, complete maxillary denture (D5110) and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record shows that you received a complete maxillary denture (D5110) and a complete mandibular denture (D5120) on May 9, 2018 and your complete maxillary denture (D5110) and complete mandibular denture (D5120) benefits have been exhausted.Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045 26 77) provided on March 24, 2020.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because the member had multiple exams on the same date of service. The Plan denied your request. The Plan says this claim is a duplicate of another which was previously processed and paid.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We find that CPT code 71045 is not supported in the record. Specifically, the record indicates that this is an exact duplicate of another claim that has been processed and paid. Additionally, the documentation submitted does not include a description of why modifier -77 was needed. Per Medicare guidance, failure to report modifier -77 and the unusual circumstances in the narrative portion of the claim will result in a claim rejection. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71045 26 77) provided on March 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an innerspring mattress (E0271).
You asked the Plan to pre-approve an innerspring mattress. You say that you had back surgery that was not
successful and regular beds are too painful for your back. You are requesting an innerspring hospital bed
mattress as recommended by your doctor. The Plan denied your request. The Plan says this item is not a
covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that the mattress can only be approved if
the beneficiary owns the hospital bed. The records show that the enrollee is renting the item.
While the mattress 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 an innerspring mattress (E0271).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing coded G0483 provided on December 5, 2019.You asked the Plan to pay forthe drug testing. 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.In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition form or medical records signed by the ordering physician stating exactly what testing was to be provided. In addition, the submitted Custom Toxicology Profile does not include the enrollee's name or date of service. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing coded G0483 provided on December 5, 2019.