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

We decided that the Plan does not have to pre-approve extreme lumbar interbody fusion (XLIF) surgery.

You asked the Plan to pre-approve these 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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have back pain. There is no documented instability, fracture, or tumor. The requested XLIF procedure is not reasonable or medically necessary at this time based on the submitted 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve extreme lumbar interbody fusion (XLIF) surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided August 13, 2019 to November 1, 2019.
You asked the Plan to pay for the glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
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 shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from August 13, 2019 to November 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) and a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on July 9, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) and a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on July 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you would benefit from continued physical and occupational therapy, and close medical oversight. The Plan denied your request. The Plan says you do not need three hours a day of therapy, or a physician to monitor medical illnesses three times a week.
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 physician reviewer found that you are at a maximum assist level for standing up to sitting. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. You are currently limited by your weight bearing restriction. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit and blood glucose test provided on September 13, 2019.
You asked the Plan to waive the deductible for the office visit and blood glucose test. You say that the provider is in-network. You say that the bill should be paid. The Plan denied your request. The Plan says the deductible applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $700. This is the amount you have to pay out-of-pocket before we will pay our share for your covered in-network medical services. Out-of-network services are not excluded from the deductible. The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" and "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $700 deductible applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the office visit and blood glucose test were received on September 13, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the office visit and blood glucose test provided on September 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 8, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Desvenlafaxine extended-release tablets.

You asked the Plan to pre-approve self-administered drugs. You say that the enrollee has been on this drug since 2011 and there should be no disruption to her current therapy. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.

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 Desvenlafaxine extended-release tablets. 

Benefits for 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the specialist office visit or the breathing tests provided on August 7, 2019.
You asked the Plan to waive the cost share for the specialist office visit and the breathing tests. You say that you are appealing these charges. 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 $50 copayment for in-network Medicare-services obtained form an in-network specialist and 20% coinsurance for in-network Medicare-covered non-radiological diagnostic services.
You have been asked to pay total cost share amount of $80.95 for the specialist office visit and the breathing tests. The specialist office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The breathing tests fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Coinsurance/Copayment
Member Liability
August 7, 2019
Specialist office visit
$113.78
$50.00
$50.00
August 7, 2019
Evaluation of wheezing
$61.72
20%
$12.34
August 7, 2019
Measurement of lung diffusing capacity
$57.38
20%
$11.48
August 7, 2019
Test for exercise induced lung stress
$35.65
20%
$7.13
Total
$80.95
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 cost share for the specialist office visit or the breathing tests provided on August 7, 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 the enrollee needs care in LTACH until she is able to discharge to a skilled nursing facility. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found as LTACHs and acute care hospital 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 acute care hospital until such time as no acute care services are required, then be transferred/discharged to a lower level of care for any ongoing long-term care needs. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the external ECG recording provided on September 5, 2019.
You asked the Plan to waive the copayment for the external ECG recording. You say that you did not see the doctor or have an ECG recording that visit. You say that there should be no copayment. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for visits to specialists. Covered services include consultation, diagnosis, and treatment by a specialist. You have been asked to pay $31.72, which is less than the standard $45 copayment for the external ECG recording. The external ECG recording falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. External ECG recording is considered a remote physician service, which applies a specialist copayment. 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 external ECG recording provided on September 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 15, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the specialist office visit or the breathing tests provided on August 7, 2019.
You asked the Plan to waive the cost share for the specialist office visit and the breathing tests. You say that you are appealing these charges. 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 $50 copayment for in-network Medicare-services obtained form an in-network specialist and 20% coinsurance for in-network Medicare-covered non-radiological diagnostic services.
You have been asked to pay total cost share amount of $80.95 for the specialist office visit and the breathing tests. The specialist office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The breathing tests fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. See chart below.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve 12 weeks of excimer laser treatment.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.
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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the records show that you have a diagnosis of vitiligo. The requested excimer laser therapy is not considered experimental or investigational in nature. The services are an appropriate treatment for vitiligo and are reasonable and 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 been met. Therefore, we decided that the Plan has to pre-approve 12 weeks of excimer laser treatment.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Soliris 900mg.
You asked the Plan to pre-approve Soliris 900mg. You say that the requested Soliris is medically necessary. The Plan denied your request. The Plan says the requested Soliris 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 Soliris 900mg. Our reviewer says that the requested Soliris is not medically necessary. Our physician reviewer found the enrollee is with myasthenia gravis. The submitted medical records include a notation in the office visit of 12/3/19 regarding testing for acetylcholine receptor antibodies. No results were submitted for review. The supported use requires the presence of positive testing for anti-acetylcholine receptor (AchR) antibodies. The drug is not FDA approved for myasthenia gravis in the absence of positive testing for the AchR antibodies. The drug is not supported in any of the CMS approved compendia in this situation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Soliris 900mg have not been met. Therefore, we decided that the Plan does not have to pre-approve Soliris 900mg.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve outpatient hospital care provided for placement of a pacemaker from August 29, to August 30, 2019.
You asked the Plan to pre-approve outpatient hospital care provided for placement of a pacemaker. You say that the services were medically necessary. The Plan denied your request. The Plan says that these services were not medically necessary.
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 outpatient hospital care provided for placement of a pacemaker. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found based on the records provided the documentation does support the medical necessity for pacemaker placement since there is report of pacemaker lead failure and consequent symptomatic complete heart block. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of outpatient hospital care provided for placement of a pacemaker have been met. Therefore, we decided that the Plan has to pre-approve outpatient hospital care provided for placement of a pacemaker from August 29, to August 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the drug combination of Keytruda, Carboplatin, and Paclitaxel with supporting drugs.You asked the Plan to pre-approve the requested drugs. The Plan denied your request. The Plan says the off-label use of the drug for the enrollee's condition is not medically accepted. 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 the requested drugs. Our physician reviewer found that the enrollee has progressive squamous cell lung cancer. The request isfor Keytruda to be given with Carboplatin and Paclitaxel with supportive Dexamethasone and Palonosetron for progression of metastatic squamous non-small cell lung cancer (NSCLC) after progression on Durvalumab and primary treatment with radiation in combination with Carboplatin and Docetaxel.The requested use is not FDA approved.The requested use is not supported by any of the CMS approved compendia.This reviewer found no supportive citations in a PubMed search.The use is not listed as not indicated, not supported or not recommended in any of the compendia.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested drugs have not been met.Therefore, we decided that the Plan does not have to pre-approvethe drug combination of Keytruda, Carboplatin, and Paclitaxel with supporting drugs.