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

We decided that the Plan does not have to pre-approve physician's services to be provided by "the doctor".You asked the Plan to pre-approve the physician's services. You say that you feel the Plan should pay for the physician's services because you have been under the care of this physician since you were 18 years old. The Plan denied your request. The Plan says there are participating providers in your area that can provide these services.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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by "the doctor".
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit.
You asked the Plan to pre-approve Procrit. You say that the requested Procrit is medically necessary. The Plan denied your request. The Plan says the requested Procrit 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 Procrit. Our reviewer says that the requested Procrit is not medically necessary. Our physician reviewer found this is a request for Procrit to be used to treat a woman with iron deficiency and chronic kidney disease not on dialysis. The use of Procrit is indicated for anemia due to chronic kidney disease per the FDA label. The label also notes: Evaluate the iron status in all patients before and during treatment. Administer supplemental iron therapy when serum ferritin is less than 100 mcg/L or when serum transferrin saturation is less than 20%. The majority of patients with chronic kidney disease will require supplemental iron during the course of erythropoietin stimulating agents (ESA) therapy. The enrollee's iron level was 2 (normal 27-139), ferritin was 17 and saturation was 1%. Therefore iron therapy is necessary. The submitted office notes of 12/24/19 and 2/6/20 indicate the enrollee does not tolerate oral iron and the prescriber was considering whether to initiate intravenous iron. The notes do not indicate intravenous iron has been started. Therefore the documentation does not support that Procrit is necessary and reasonable and that it is not safe and effective at this point in time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627).
You asked the Plan to pre-approve the seat lift mechanism. You say that this item is medically necessary. The Plan denied your request. The Plan says medical necessity criteria have not been 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 the seat lift mechanism. Our reviewer says that the documentation does not support that the requirements for Medicare coverage have been met based on the LCD. Our physician reviewer found according to the physical therapy visit note dated January 16, 2020, the enrollee is able to rise from a chair with arms requiring supervision, therefore the documentation does not support that the seat lift mechanism is medically reasonable and necessary 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 the seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism (E0627).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee. You asked the Plan to pre-approvethese 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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrolleehas a diagnosis of malignant neoplasm of the lateral wall of the bladder. There are no findings suspicious for FDG-avid metastatic disease on PET scan imaging. Keytruda is currently indicated for the treatment of patients with Bacillus Calmette-Guerin (BCG)-unresponsive, high-risk, non-muscle invasive bladder cancer with carcinoma in situ, with or without papillary tumors who are ineligible for, or have elected not to undergo, cystectomy. There are insufficient data in the medical literature to support that Keytruda is medically reasonable and necessary for patients with bladder cancer. The medication is not reasonable or medically necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approveKeytruda for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve follow-up urology care from a tertiary level provider.
You asked the Plan to pre-approve the tertiary level urology services. You say that you feel that you should be allowed to continue with this provider. The Plan denied your request. The Plan says your condition can be adequately managed by non-tertiary network providers.
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 tertiary level urology services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a male with BPH with lower urinary tract symptoms. He has been treated in the past with doxazosin and tamsulosin. He has erectile dysfunction and uses tadalafil 20 mg. daily. He has hypogonadism that is managed with testosterone injections by his primary care physician. Most recent PSA was 4.1 ng/mL. Request is for coverage of follow-up for BPH and hypogonadism to be provided by a tertiary level provider. The enrollee's condition is not so complex as to require tertiary care. He can be managed by a non-tertiary urologist. BPH, hypogonadism and erectile dysfunction can usually be managed outside of the tertiary care setting unless there are unusual co-morbidities. The medical records provided indicate that this patient could be easily managed outside of the tertiary care setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the tertiary level urology services have not been met. Therefore, we decided that the Plan does not have to pre-approve follow-up urology care from a tertiary level provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered from October 9, 2019 to October 30, 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 enrollee was on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on October 6, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the services rendered from October 9, 2019 to October 30, 2019.
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 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. 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 services are not medically necessary. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH). Initially admitted due to a humerus fracture, the enrollee was later discovered to have cancer with obstruction of the airway. The enrollee was intubated and subsequently received a tracheotomy. The enrollee is not on a ventilator. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT codes 95937 and 95940 provided on August 12, 2019.
You asked the Plan to pay for CPT codes 95937 and 95940. You say that the medical records support the billing of CPT codes 95937 and 95940. The Plan denied your request. The Plan says the medical records do not support the billing of CPT codes 95937 and 95940.
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 95937 is Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method, and code 95940 is Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure). 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 CPT codes 95937 and 95940. Our reviewer says that the medical records do not support the billing of CPT codes 95937 and 95940. Our physician reviewer found the medical records do not support the billing of CPT code 95937. In short, CPT code 95937 is defined as "neuromuscular junction testing (repetitive stimulation, paired stimuli) each nerve, any one method". CPT code 95937 is otherwise commonly and customarily billed when used in the evaluation of disorders of the neuromuscular junction (NMJ). In this case the enrollee did not undergo evaluation for a NMJ disorder. The testing done (train of four testing) only evaluates muscular response to determine the reliability of other signals (that are being monitored). The testing was not done in and of itself as a formal diagnostic procedure. In that regard it can be said that the service billed for is not otherwise supported by the records. The medical records also do not support billing of CPT code 95940 either. 95940 requires that the monitoring physician be present in the operating room performing intraoperative monitoring (in real time). In this case the records provided for review clearly demonstrated that the billing provider was monitoring the procedure remotely. This was demonstrated by the physician's communication with the technologist via a real time chat-log. Furthermore the HCFA-1500 form submitted for review also included a charge for G0453 (which
represents remote monitoring). CPT codes 95940 and G0453 are not otherwise supposed to be billed together. For all of these reasons 95940 is not supported in this case. As such it can be concluded that neither CPT code under review in this case is supported by the records. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT codes 95937 and 95940 have not been met. Therefore, we decided that the Plan does not have to pay for CPT codes 95937 and 95940 provided on August 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that IRF care is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.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. Our physician reviewer found thecomplexity of the nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not show the currentmedical status requires the intensity of an IRF stay with close physician or nursing supervision. The documentation notes you have malaise and fatigue. The notes do not indicate a need for an intensive rehabilitation facility therapy program level 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-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that on the date of service you awoke sweating and unstable. You wokeyour wife who tried to administer usual remedies for low blood sugar levels. After you became unresponsive, your wife called for an ambulance. The responders arrived and treated you to bring your blood sugar levels to an acceptable level. You say that since your sugar levels had stabilized you did not need to be transported to the hospital.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 26, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lymph node biopsy surgery provided on November 13, 2019.You asked the Plan to waive the copayment for the lymph node biopsy surgery. You say that the copayment is incorrect because the biopsy was performed in the ultrasound department and you were not told of the cost. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.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 $400 copayment per day of service. You have been asked to pay a $400 copayment for the lymph node biopsy surgery. The lymph node biopsy surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 towaive the copayment forthe lymph node biopsy surgery provided on November 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the operating room services provided from October 14, 2019 to November 22, 2019.
You asked the Plan to waive the copayments for the operating room services. You say that you should only be charged the office visit copayment instead of a $173.40 for the treatments. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $400 copayment for in-network Medicare-covered outpatient hospital surgery services. For each date of service, you have been asked to pay the allowed amount of the claim because these amounts are less than the $400 copayment for surgery services in an outpatient hospital.
You have been asked to pay a $173.40 copayment for the operating room services on each date of service. The operating room services fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 copayments for the operating room services provided from October 14, 2019 to November 22, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Planhasto pre-approvethe Inspire implant for the enrollee.You asked the Planto pre-approvethe implant. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthere is no evidence of a condition for which the medical literature supports the use of this request.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the implant. Our reviewer says that the requested implant is considered medically reasonable and necessary in this case. Our physician reviewer found implantation of the Inspire device is considered reasonable and medically necessary for this patient. There are multiple well-designed studies, although mostly without sham controls, demonstrating benefits of the device in selected patients, with acceptable risk levels. Benefits appear to persist to at least 4 years. Various society guidelines are acknowledging this treatment as an effective second-line therapy in selected patients intolerant of CPAP.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 implant havebeen met.Therefore, we decided that the Planhas to pre-approvethe Inspire implant for the enrollee.If the Plandoes 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/orsend us the new information. This doesnot happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that you would like to see the provider. The Plan denied your request. The Plan says there are in-network providers.available for these services.
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 an office visit to be provided by an out of network (OON) provider.