Persius/hicric huggingface dataset:
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 the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for congestive heart failure and chronic obstructive pulmonary disease (COPD) exacerbation. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
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 the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 the complexity of the enrollee nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a stroke. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee 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 enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four custom fabricated abutments (D6057 x4).
You asked the Plan to pre-approve the custom fabricated abutments. You say that these services are medically necessary for the enrollee. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit package.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve four custom fabricated abutments (D6057 x4).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the EKG provided on September 25, 2020.

You asked the Plan to waive the co-payment for the EKG. You say that you are requesting that this charge be waived. The Plan denied your request. The Plan says you have been asked to pay 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 $30 co-payment for Medicare-covered non-radiological diagnostic services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $30 co-payment for the EKG.

You have been asked to pay a $12.44 co-payment for the EKG. The EKG falls 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 co-payment for the EKG provided on September 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical procedure provided on August 4, 2020 billed with CPT code 28002.

You asked the Plan to pay for the surgical procedure as billed. You say that it is felt that the billed codes are clearly documented. The Plan denied your request. The Plan says review of the operative report does not support payment for code 28002.

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 28002 is Incision and drainage below fascia, with or without tendon sheath involvement, foot; single bursal space.

We asked our coding 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 surgical procedure as billed. Our reviewer says that the billed procedure code is not supported by the operative report. Our coding reviewer found the medical records provided do not include sufficient documentation to validate the services billed. Coding descriptions in regard to code 28002 state that "An incision is made through skin and fascia to expose the infection. The infected tissue is removed, and the bursal sac may be removed or simply incised and drained. If the wound is large, the physician may leave the incision open after irrigating the area, treating it with antibiotic, and packing it with petroleum gauze." This description was not documented in the report.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgical procedure as billed have not been met. Therefore, we decided that the Plan does not have to pay for the surgical procedure provided on August 4, 2020 billed with CPT code 28002.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for an out-of-network primary care visit.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are network providers available.
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 a referral for an out-of-network primary care visit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
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 you have severe pain after wearing shoes. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve GenVisc 850.

You asked the Plan to pre-approve GenVisc 850. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy criteria have not been met.

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 GenVisc 850. Our reviewer says that the criteria for coverage of GenVisc 850 have not been met. Our physician reviewer found the Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. While the records show that the enrollee had no relief with Monovisc, it is not documented that Orthovisc would likely be less effective or have adverse effects for the enrollee in this case. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of GenVisc 850 have not been met. Therefore, we decided that the Plan does not have to pre-approve GenVisc 850.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four crowns (D2752 x4).
You asked the Plan to pre-approve the crowns. You say that you need these crowns to be approved for coverage. The Plan denied your request. The Plan says the maximum coverage amount for the contract/calendar year has been exhausted.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a maximum plan benefit coverage amount of $1,000 per year, which applies to all supplemental (i.e., routine) dental services - both preventive and additional comprehensive - covered by the Plan. The contract says that you are responsible for any cost above the $1,000 maximum. The record shows that you were approved for coverage partial dentures on January 27, 2021 which met the $1,000 annual maximum benefit, and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve four crowns (D2752 x4).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity (J3111).
You asked the Plan to pre-approve Evenity. You say that this drug is medically necessary for the enrollee. The Plan denied your request. The Plan says step therapy criteria have not been met.
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 Evenity. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found that the enrollee has a diagnosis of age-related osteoporosis without current pathological fracture. It is noted that the enrollee needs aggressive treatment. The case file does not contain documentation of trial and failure of Forteo or Tymlos, the Plan's required step-therapy drugs. The documentation does not support that Forteo or Tymlos would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to pre-approve Evenity (J3111).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve comprehensive BRCA 1 and 2 and BART testing.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says there is no personal history of breast, ovarian, or pancreatic cancer.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the testing, is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve comprehensive BRCA 1 and 2 and BART testing.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Erbitux (J9055), Carboplatin (J9045), and Paclitaxel (J9267).
You asked the Plan to pre-approve Erbitux, Carboplatin, and Paclitaxel. You say that this request is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that the drug is helpful for the enrollee's condition.
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 Erbitux, Carboplatin, and Paclitaxel. Our reviewer says that the requested drugs are not medically necessary and reasonable. Our physician reviewer found these requested drugs are for a patient with metastatic salivary gland cancer. In this case, there is no compendia basis or literature support for these requested drugs in salivary gland cancers. This regimen, while approved for squamous cell cancer of head and neck, is not supported for the enrollee's specific cancer. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Erbitux, Carboplatin, and Paclitaxel have not been met. Therefore, we decided that the Plan does not have to pre-approve Erbitux (J9055), Carboplatin (J9045), and Paclitaxel (J9267).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two bone grafts at the time of implant placements (D6104 x2).
You asked the Plan to pre-approve the bone graft. You say that the enrollee needs these services. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two bone grafts at the time of implant placements (D6104 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement prosthesis for the enrollee to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve a replacement prosthesis. You say that the member would like to continue to see this prosthetist. The Plan denied your request. The Plan says that there are in-network providers available.

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 a replacement prosthesis for the enrollee to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Interspinous Spacer.
You asked the Plan to pre-approve the Vertiflex Superion Spacer. You say that you would like reconsideration because this procedure is medically necessary. The Plan denied your request. The Plan says the requested procedure is experimental.
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 Vertiflex Superion Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested procedure is considered experimental as more research is needed to determine its safety and efficacy. 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 Vertiflex Superion Spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Interspinous Spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.

You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant for tooth #'s 19 and 20.
You asked the Plan to pre-approve the endosteal implants. The Plan denied your request. The Plan says these services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant for tooth #'s 19 and 20.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a continuous glucose monitor and supplies.

You asked the Plan to provide coverage for a continuous glucose monitor and supplies. You say that this device is medically necessary. The Plan denied your request. The Plan says all the required Medicare coverage criteria are not met. The Qualified Independent Contractor (QIC) overturned the Plans denial stating this equipment could be beneficial. The Plan requested a reopen and stated that the issue was not whether or not this device would be beneficial but that the criteria are clear that all conditions in the LCD must be met for coverage. The Plan states the medical records do not show that you are treated with insulin three or more times per day.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on the medical records provided, you do not meet all of the criteria required for coverage of this device. Therefore, we decided that the Plan does not have to provide coverage for a continuous glucose monitor and supplies.