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

We decided that the Plan does not have to pay for the self-administered drugs provided from April 29, 2021, to
May 1, 2021.
You asked the Plan to pay for the self-administered drugs. You say that the doctor put you on a new medication
for your Parkinson disease. You also say that you were not given any medications for pneumonia. The Plan
denied your request. The Plan says self-administered drugs are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs
provided from April 29, 2021, to May 1, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Actemra Inj Actpen.

You asked the Plan to pre-approve Actemra Inj Actpen. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Actemra Inj Actpen.

Benefits for Actemra Inj Actpen may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on February 19, 2021.
You asked the Plan to pay for the self-administered drugs. You say that he was told not to bring his regular pills and were told by the hospital this should be charged under Part D. You say that he is disabled, on social security and this is not a bill he should incur. The Plan denied your request. The Plan says the claim processed correctly.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided on February 19, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the MI profile services provided on December 16, 2020.

You asked the Plan to pay for the MI profile services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that MI profile services are not listed as a covered test by Palmetto. 

We looked at the file and Medicare rules. Review of the file shows that the services rendered were an MI profile. MI profile is not listed as a covered benefit. Based on this information, we decided that Medicare rules for coverage of the MI profile services have not been met. Therefore, we decided that the Plan does not have to pay for the MI profile services provided on December 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve group 3 power mobility device features (E2300 and E2331).

You asked the Plan to pre-approve power mobility device features. You say that the features should be covered. The Plan denied your request. The Plan says they will overturn the request for a group 3 power wheelchair, but not the seat elevation feature (E2300) or attendant control (E2331) are not covered.

The Plan follows Medicare rules. Medicare rules say that power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. The rules also say that if an attendant control (E2331) is provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered. Therefore, we decided that the Plan does not have to pre-approve group 3 power mobility device features (E2300 and E2331).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services provided on February 10, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for injection services. You say that you are appealing with records and request payment based on medical necessity. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not 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 had network providers available who could have provided 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 injection services provided on February 10, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that the requested item is necessary. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional physical therapy visits.
You asked the Plan to pre-approve the additional physical therapy visits. You say that the additional visits are medically necessary. The Plan denied your request. The Plan says 6 additional visits were already approved. 6 more are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that PT services are covered services provided the services are of a level of complexity and sophistication, or the patient's condition is such that the services can be safely and effectively performed only by a licensed physical therapist 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 additional physical therapy visits. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the patient's condition beyond what was approved by the health plan. The patient has had prior therapy for this condition and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment. 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 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 additional physical therapy visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management provided on August 7, 2020 by an OON provider.

You asked the Plan to pay for the hospital discharge day management. You say that the rendering physician depends upon the hospital staff to verify eligibility and to obtain the proper authorization for In-Network and Out-of-Network providers from the enrollee's insurance company. The Plan denied your request. The Plan says the services were rendered by a non-participating provider. The Plan also says that prior authorization was not 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 had network providers available who could have provided 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 hospital discharge day management provided on August 7, 2020 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for positron emission tomography (PET) scan provided on March 11, 2021.

You asked the Plan to pay for a PET scan.. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed with an appropriate diagnosis.

The Plan must follow Medicare rules. Medicare rules say that PET scans must be billed with an appropriate diagnosis code. 

We looked at the file and Medicare rules. The billed diagnosis code, C18.9, is not listed as an appropriate code. Based on this information, we decided that Medicare rules for coverage of a PET scan. have not been met. Therefore, we decided that the Plan does not have to pay for positron emission tomography (PET) scan provided on March 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on May 8, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on May 8, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the flexible colonoscopy with directed submucosal injections (45381XU) provided on February 12, 2021.

You asked the Plan to pay for the flexible colonoscopy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the documents received do not support that the procedure or service was distinct or independent from other services performed.

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 45381-XU is colonoscopy, flexible; with directed submucosal injection(s), any substance.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the flexible colonoscopy. Our reviewer says that the procedures are distinct. The elements of the coverage criteria are satisfied. Our physician reviewer found the record indicates that the enrollee had a colonoscopy for bleeding. A friable area of tissue was identified that was unable to be cauterized.  A tattoo was placed at this area.

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 flexible colonoscopy have been met. Therefore, we decided that the Plan has to pay for the flexible colonoscopy with directed submucosal injections (45381XU) provided on February 12, 2021. 

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on January 22, 2021.

You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Cardiovascular risk assessment panels are only covered for certain indications. 

Review of the file shows that the plan uses Local Coverage Determination (LCD) L36523 to support their denial. However, LCD L36523 is not valid for the provider's billing state of Texas. Therefore, we are unable to use LCD L36523 to substantiate our decision. 

While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on January 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.

You asked the Plan to pre-approve a portable ventilator. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that ventilators (E0465, E0466) are covered for specific conditions. 

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 portable ventilator. Our reviewer says that the item is not medically necessary. Our physician reviewer found the review indicates that the enrollee does not meet the coverage criteria. 

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 portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on February 24, 2020 by a nonparticipating
provider.

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 were rendered by a non-participating provider without prior authorization.

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 had network providers
available who could have provided 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 home visit provided on February 24, 2020 by a
non-participating provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the services are medically necessary based on dementia, other diseases and behavioral disturbances. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 enrollee has remained medically stable and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. The enrollee is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a SNF. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. The enrollee is medically stable without any acute exacerbations of chronic medical problems. The enrollee's physical function is at or near their baseline and they can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is not 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Mvasi, Fluorouracil, and Irinoteca.
You asked the Plan to pre-approve Mvasi, Fluorouracil, and Irinoteca. You say that the medications are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 Mvasi, Fluorouracil, and Irinoteca. Our reviewer says that the medications are not medically necessary. Our physician reviewer found this combination is not FDA approved or supported by major drug compendia for the medical literature. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Mvasi, Fluorouracil, and Irinoteca have not been met. Therefore, we decided that the Plan does not have to pre-approve Mvasi, Fluorouracil, and Irinoteca.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (71045) provided on April 5, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a column II code
and is not payable.
The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair,
the column two code is denied, and the column one code is eligible for payment. Procedure code 71045 is part
of an edit pair with procedure code 77001. Procedure code 77001 is a column one code, and procedure code
71045 is a column two code. Procedure code 77001 has been paid for this date of service, which means that
procedure code 71045 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for
the services (71045) provided on April 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies provided on April 9, 2021.

You asked the Plan to pay for the CGM supplies. You say that this was approved by the Plan, and the enrollee meets the criteria for coverage. The Plan denied your request. The Plan says the medical records submitted do not include sufficient evidence that the criteria are met in this case.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The most recent progress note is from a month before the CGM was ordered. This note does not document the intention to order a CGM nor does it document that the criteria are met. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Although this was approved by the Plan, the DME provider is still required to maintain supporting records on file. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies provided on April 9, 2021.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says your needs can be met at a different level of care.
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. Our physician reviewer found based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF 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 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.