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

We decided that the Plan does not have to pay for the inpatient physician services provided on July 31, 2020, billed with code 99254.

You asked the Plan to pay for the inpatient services as billed. You say that the enrollee was being treated emergently and had no choice as to the participation status of the treating physician. The Plan denied your request. The Plan says these services were billed with an invalid code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

CPT code 99254 has a status indicator of "I" in the Physician Fee Schedule, meaning it is invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the inpatient services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient physician services provided on July 31, 2020, billed with code 99254.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Prolia 60mg/ml Syringe medication (J0897).

You asked the Plan to pre-approve this medication. You say that this medication is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of this medication.

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 this medication. Our reviewer says that the enrollee does not meet criteria for coverage of this medication. Our physician reviewer found that the enrollee has a history of osteoporosis. The Plan requires a trial of drug Zoledronic acid before they will approve the requested drug. In this case, the patient has not tried and failed the required drug. There is no documentation provided indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this medication have not been met. Therefore, we decided that the Plan does not have to pre-approve the Prolia 60mg/ml Syringe medication (J0897).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the destruction of spinal facet joint nerves using imaging guidance provided on December 9, 2020.

You asked the Plan to waive the co-payment for the destruction of spinal facet joint nerves using imaging guidance. You say that you should not have a co-payment. You say your first appeal on September 9, 2020 was adjusted to a $0 co-payment. The Plan denied your request. The Plan says your appeal on September 9, 2020 was adjusted in error. 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $450 co-payment for surgery services at an outpatient hospital.

You have been asked to pay a $450 co-payment for the destruction of spinal facet joint nerves using imaging guidance. The destruction of spinal facet joint nerves using imaging guidance falls within the "Outpatient hospital services" 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 co-payment for the destruction of spinal facet joint nerves using imaging guidance provided on December 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the anti-neoplastic chemotherapy provided on May 18, 2020 to May 25, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the anti-neoplastic chemotherapy. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 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 anti-neoplastic chemotherapy provided on May 18, 2020 to May 25, 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 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 in the Medicare rules section.
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
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for gastrointestinal
bleeding and anemia. The enrollee's medical problems are stable. There are no complex nursing or
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record
supports a need for physical and/or occupational therapy, there is no documented need for intensive
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ultraviolet multidirectional light therapy system in 6 foot cabinet, includes bulbs/lamps, timer and eye protection (CPT code E0694), for the enrollee.

You asked the Plan to pre-approve the ultraviolet multidirectional light therapy system. You say that this enrollee has a diagnosis of Probable Mycosis Fungoides LCD-10 code C84.00. You state this enrollee would benefit of use of UV device for their diagnosis. The Plan denied your request. The Plan says this is not covered by Medicare for the enrollee's condition.

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 ultraviolet multidirectional light therapy system. Our physician reviewer found the medical records provided do not meet the requirements listed in the NCD for Medicare coverage until the diagnosis of mycosis fungoides is confirmed by the biopsy results. 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 ultraviolet multidirectional light therapy system have not been met. Therefore, we decided that the Plan does not have to pre-approve ultraviolet multidirectional light therapy system in 6 foot cabinet, includes bulbs/lamps, timer and eye protection (CPT code E0694), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computer-assisted surgical navigation and inpatient
level of care for should joint replacement surgery.

You asked the Plan to pre-approve computer-assisted surgical navigation and inpatient care. You say that the
enrollee's pain is getting worse, and it became worse after physical therapy. The Plan denied your request. The
Plan says the denial of authorization for these services is correct, because computer-assisted surgical navigation
is not covered, and this surgery can be performed as an ambulatory procedure with inpatient level of care
consideration given if the enrollee experiences peri- or post-operative complications.

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 computer-assisted surgical navigation
and inpatient care. Our reviewer says that the requested items/services are not considered medically reasonable
and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding
significant comorbidities that would require an inpatient authorization prior to this surgery. The documentation
provided does not definitively support a greater than 2 midnight stay. Applicable peri- or post-operative
complications can result in reconsideration of inpatient level of care based on concurrent review. Furthermore,
the use of computer navigation for total shoulder procedures has limited, published peer-reviewed literature
that shows the request to be an effective/meaningful treatment. This is due to the lack of significant ultimate
clinical outcome differences as compared to non-navigated shoulder replacements. There is no compelling
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an
exception to guidelines.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of computer-assisted surgical navigation and inpatient care have not been met.
Therefore, we decided that the Plan does not have to pre-approve computer-assisted surgical navigation and
inpatient level of care for should joint replacement surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311,
E2313, E2377) for the enrollee.

You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied
your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the accessories. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the documentation does not reveal that the enrollee requires other types of proportional input
devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional
input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more
powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other
electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive
control), or an attendant control. The enrollee's ability to feed herself indicates that the patient can control any
power options through their own individual switches.

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 accessories have not been met. Therefore, we decided that the Plan does not
have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the introduction of long gastrointestinal tube services coded
44500, and the unlisted procedure code 30999 provided on December 22, 2020.
You asked the Plan to pay for the introduction of long gastrointestinal tube services and the unlisted 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 separately 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.
We find that CPT codes 44500 and 30999 are not supported in the medical record. Specifically, these services
were provided while the enrollee was inpatient in a hospital setting. This means these services are included in
the inpatient payment made. These services are not separately payable. Based on this information, we decided
that Medicare rules for coverage of the introduction of long gastrointestinal tube services and the unlisted
procedure have not been met. Therefore, we decided that the Plan does not have to pay for the introduction of
long gastrointestinal tube services coded 44500, and the unlisted procedure code 30999 provided on December
22, 2020.
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 are unable to sit or stand in the shower. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxaliplatin.

You asked the Plan to pre-approve Oxaliplatin. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.

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 Oxaliplatin. Our reviewer says that the documentation does not support that the requested drug is medically necessary. Our physician reviewer found the enrollee has stage IV esophageal cancer. The case file indicates that the requested drug is being given with fluorouracil and leucovorin or possibly with the addition of Kaytruda. The Medicare approved compendia do not contain positive citations for the use of either combination for the diagnosis being treated. Therefore, the enrollee does not meet criteria for the requested drug. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Oxaliplatin have not been met. Therefore, we decided that the Plan does not have to pre-approve Oxaliplatin.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression clothing provided November 3, 2020.

You asked the Plan to pay for the compression clothing. You say that this clothing helps with muscle pain. The Plan denied your request. The Plan says this 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. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. 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 pay for the compression clothing provided November 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan of extracranial arteries (99072, 93880) provided December 11, 2020.

You asked the Plan to waive the copayment for the duplex scan of extracranial arteries. You say that you were under the impression this would be completely covered. The Plan denied your request. The Plan says the copayment processed correctly, and no reimbursement is due.

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 $40 copayment for outpatient diagnostic tests and therapeutic services and supplies.

You have been asked to pay a $40 copayment for the duplex scan of extracranial arteries. The services provided fall within the outpatient diagnostic tests and therapeutic services and supplies 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 the duplex scan of extracranial arteries (99072, 93880) provided December 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6531.

You asked the Plan to pre-approve the compression stockings. You say that the item is medically necessary for your condition. The Plan denied your request. The Plan says the compression stockings are not necessary for your situation.

The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.

The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6531.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat radiofrequency ablation (RFA) of the genicular nerves.

You asked the Plan to pre-approve RFA. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve RFA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have bilateral osteoarthritis of her knees. She takes Advil and Tylenol for pain. You have had injections, but these have become less effective. You have RFA of the genicular nerves in the past with excellent results. You are also doing Chiropractic therapy and a Home exercise program. The request is considered an experimental/ investigational procedure. It is the subject of on-going clinical trials. Therefore, you do not meet criteria for the requested services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat radiofrequency ablation (RFA) of the genicular nerves.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a positron emission tomography (PET) with computerized
tomography (CT) scan.

You asked the Plan to pre-approve a PET scan. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says that the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are
medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a PET scan. Our reviewer says that the
documentation does support that the requested services are medically reasonable or necessary. Our physician
reviewer found the enrollee has enlarged bilateral axillary lymph nodes. In this case, the enrollee does not have
a diagnosis of cancer. No biopsy has been performed that is strongly suggestive of cancer. However, the
enrollee has characteristics strongly suspicious of cancer. Therefore, the enrollee meets criteria for the
requested PET with CT scan.

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 PET scan have been met. Therefore, we decided that the Plan has to pre-approve
a positron emission tomography (PET) with computerized tomography (CT) scan.

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.