Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing visits.
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says the approved visits will allow for the education of a home program.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. The file shows that 6 home health skilled nursing visits were requested. The Plan has agreed to pre-approve 2 visits. 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 additional home health services. Our physician reviewer found that the enrollee does not have documented skilled nursing needs (i.e., IVs, complex wound care, new ostomy). As such, the requested, ongoing, services are not medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a urinary drainage bag on January 26, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says payment for this code is always bundled into payment for other services not specified.
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 A5112 is "Urinary drainage bag, leg or abdomen, latex, with or without tube, with straps, each." We find that procedure code A5112 is not supported in the medical record. Specifically, this code has a status indicator of "P" which means that it cannot be billed separately. Payment for this code is always bundled into payment for other services not specified. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for a urinary drainage bag on January 26, 2021
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the fixed wing air transport (A0430) and fixed wing air mileage (A0435) provided on December 18, 2020.  You asked the Plan to pay for the fixed wing air transport and air mileage. You say that you believe this claim was denied in error. The Plan denied your request. The Plan says this service is not covered. The Plan also says that Medicare only covers air transport to a hospital.  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 the fixed wing air transport (A0430) and fixed wing air mileage (A0435) are not supported in the medical record. Specifically, this claim was billed with modifier II, indicating that the member was picked up and dropped off at a transfer site. The records indicate that the drop-off site was a hospital. In this case, modifier II is not appropriate. Based on this information, we decided that Medicare rules for coverage of the fixed wing air transport and air mileage have not been met. Therefore, we decided that the Plan does not have to pay for the fixed wing air transport (A0430) and fixed wing air mileage (A0435) provided on December 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the dental consultation and cone beam computed tomography (CT) scan provided May 27, 2021, and biopsy and implant removal provided June 3, 2021.  You asked the Plan to pay for the dental consultation, cone beam x-ray, biopsy and removal of implant. You say that you were in pain from an infection and needed the services performed. The Plan denied your request. The Plan says these services are not covered when provided OON.  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. The Plan covers the dental consultation, cone beam x-ray, biopsy and removal of implant when the services are provided by a provider in the Plan's dental vendor network.  We looked at the file and Medicare rules. 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 dental consultation and cone beam computed tomography (CT) scan provided May 27, 2021, and biopsy and implant removal provided June 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 27, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the service was not supported by the procedure code billed on this claim.
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 27, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve use of Hizentra.
You asked the Plan to pre-approve Hizentra. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because there is no documentation of recurrent infection and the enrollee's immunoglobulin levels were normal.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Hizentra. Our reviewer says that the enrollee meets the criteria for the requested use of Hizentra. Our physician reviewer found the enrollee has a diagnosis of primary immunodeficiency. The Food & Drug Administration has stated that Hizentra is indicated for the treatment of primary immunodeficiency in adults and pediatric patients 2 years and older. The requested service is recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hizentra have been met. Therefore, we decided that the Plan has to pre-approve use of Hizentra.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm (J3590).
You asked the Plan to pre-approve Aduhelm. You say that Aduhelm is medically necessary. The Plan denied your request. The Plan says 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 Aduhelm. Our reviewer says that Aduhelm is not medically necessary. Our physician reviewer found Aduhelm is FDA-approved for the treatment of Alzheimer's disease. The documentation is insufficient to support a diagnosis of Alzheimer's disease in this enrollee. The objective assessment of cognitive function is normal in this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm (J3590).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided from August 31, 2020, to
September 4, 2020, and billed with diagnosis related group (DRG) 871.
You asked the Plan to pay for the inpatient care billed with DRG 871. You say that there is a clear and
consistent documentation of sepsis in the medical records, and the billing of these claims is appropriate.
The Plan denied your request. The Plan says the billing of DRG 871 is not supported in the record. According
to coding guidelines and documentation in the medical record, the enrollee's condition did not qualify for
reporting Sepsis as the principal diagnosis code. The Plan says that the review supports the billing of a different
DRG.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes. DRG 871 requires a primary diagnosis of Sepsis.
In this case, you billed the medically necessary inpatient services provided with DRG 871. 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 inpatient care billed with DRG 871. Our reviewer says
that the submitted DRG is not supported in the record. Our physician reviewer found that the documentation
supports an inpatient admission for pneumonia due to Pseudomonas. The documentation is unclear regarding a
diagnosis of sepsis. Although Sepsis is documented throughout the medical record, supporting medical
documentation was not found. The review has determined that the medical records did not support the billing
of Sepsis due to E-Coli (A41.51) and/or Sepsis due to unspecified organism (A41.9).
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 inpatient care billed with DRG 871 have not been met. Therefore, we
decided that the Plan does not have to pay for the inpatient hospital care provided from August 31, 2020, to
September 4, 2020, and billed with diagnosis related group (DRG) 871.
Sincerely,
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gemtesa tablets.
You asked the Plan to pre-approve the Gemtesa tablets. The Plan denied your request. The Plan says Gemtesa is a self-administered drug and does not fall under Part B 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 Gemtesa tablets.
Benefits for Gemtesa tablets 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
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 enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. He has severe foraminal stenosis at the requested levels for treatment. Based on the submitted records, the Superion spacer is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the muscle-skin graft services coded 15738 provided on April 28, 2021.
You asked the Plan to pay for the muscle-skin graft services. 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 supported by the documentation.
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 15738 is muscle, myocutaneous, or fasciocutaneous flap; lower extremity. We find that CPT code 15738 is not supported in the medical record. Specifically, the operative report does not include documentation of a lower extremity muscle, myocutaneous, or fasciocutaneous flap; therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the muscle-skin graft services have not been met. Therefore, we decided that the Plan does not have to pay for the muscle-skin graft services coded 15738 provided on April 28, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for outpatient vision care physician services provided on August 11, 2021.
You asked the Plan to reduce the copayment for the vision care physician services. You say that this should have been processed as a vision care outpatient physician services with a $15 copay. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $0 copayment for diagnosis and treatment for diseases and conditions of the eye. The Plan says you must pay a $25 copayment for vision care physician services. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for vision care physician services. Therefore, we decided that the Plan has to waive the copayment for outpatient vision care physician services provided on August 11, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zarxio.
You asked the Plan to pre-approve Zarxio. The Plan denied your request. The Plan says the enrollee's chemotherapy treatment has low risk for neutropenic fever.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Zarxio. Our physician reviewer found that in this case, the record indicates the enrollee has a diagnosis of metastatic non-small cell lung cancer. The enrollee is being treated with a regimen of Keytruda, Pemetrexed, and Carboplatin. He previously developed leukopenia in November 2021. The record indicates that the enrollee has a normal white blood cell count. The FDA has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zarxio have not been met. Therefore, we decided that the Plan does not have to pre-approve Zarxio
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. There is no indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain her functional status. The enrollee is ambulating short distances and can receive services at a lower 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.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
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 enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from December 3, 2021, forward.
You asked the Plan to pre-approve inpatient psychiatric care from December 3, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 inpatient psychiatric care from
December 3, 2021, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental
health treatment from December 3, 2021, forward. Our physician reviewer found you did not require inpatient
mental health treatment from December 3, 2021, forward as you were not a danger to yourself or others and did
not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking
place. It did not appear that the services for the dates in question were reasonably expected or medically
necessary to improve your condition or for the purpose of diagnosis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient psychiatric care from December 3, 2021, forward have not been met.
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from December 3,
2021, forward.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says a step therapy exception cannot be granted.

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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee has anemia of chronic kidney disease and is not on dialysis. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. 

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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit for the enrollee.