Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the deductible for X-Ray services (71046)
You asked the Plan to waive the deductible for X-Ray services. You say that the services should be covered as you had met your deductible for 2020. The Plan denied your request. The Plan says that the cost sharing applied correctly as you met your deductible for 2021, which was when the claim was received.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. We reviewed the file and find that the Plan has failed to provide definitive evidence to show that your 2020 deductible had not been met by the time this claim was received and paid on July 11, 2021. The Plan stated that the charge would be applied to your 2021 deductible since it was received in 2021. This is incorrect. Moreover, you provided evidence showing that your 2021 deductible was met as of February 14, 2021, from an outpatient surgery claim. In addition, the original Explanation of Benefits for this x-ray from September 13, 2020, shows that your 2020 deductible had already been met at the time this claim was denied. Since the Plan did not show the reason that the plan year 2020 $300 deductible went from being met in 2020 to not met in 2021, we find that the Plan has not substantiated applying this service to the deductible in this case. Therefore, we decided that the Plan has to waive the deductible for X-Ray services (71046)
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services 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 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 you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You appear to have reached a plateau in function. Ongoing daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Jevtana with Fulphila.
You asked the Plan to pre-approve Jevtana with Fulphila. You say that Jevtana is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested drug regimen is considered investigational/experimental 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 Jevtana with Fulphila. Our reviewer says that the requested drug regimen is not medically reasonable and necessary. Our physician reviewer found the enrollee has been diagnosed with metastatic castration-resistant prostate cancer. In this case, the requested drug regimen is not FDA-approved for the enrollee's condition as the enrollee has not yet received docetaxel. In addition, the use of the drug regimen for the enrollee's condition is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Jevtana with Fulphila have not been met. Therefore, we decided that the Plan does not have to pre-approve Jevtana with Fulphila.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Coflex interspinous device.
You asked the Plan to pre-approve a Coflex interspinous device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 a Coflex interspinous device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Coflex device is experimental. More research is needed to show safety and efficacy of the device. High failure rates have been reported with similar devices. 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 Coflex interspinous device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Coflex interspinous device
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the abdomen (74183) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an MRI of the abdomen to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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 magnetic resonance imaging (MRI) of the abdomen (74183) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc or Synvisc-one.
You asked the Plan to pre-approve Synvisc or Synvisc-one. You say that the services are 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 viscosupplementation therapy for the knee via intra-articular injections of hyaluronic preparations will be considered medically reasonable and necessary when specific criteria are met. 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 Synvisc or Synvisc-one. Our reviewer says that the services are not medically necessary. Our physician reviewer found the record does not indicates that the enrollee has failed a three-month course of conservative therapy. The elements of the coverage criteria are not satisfied. The requested service is not 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 Synvisc or Synvisc-one have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc or Synvisc-one.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift.
You asked the Plan to pre-approve a stair lift. You say that the item is necessary. The Plan denied your request. The Plan says the requested item is not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a stair lift.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you still have doctor appointments and have no other means of transportation. The Plan denied your request. The Plan says the benefit for routine transportation has been exhausted at this time.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
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 services 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 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's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methotrexate.
You asked the Plan to pre-approve Methotrexate. 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 Methotrexate.
Benefits for Methotrexate 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Abraxane.
You asked the Plan to pre-approve Abraxane. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 Abraxane. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the provided records do not indicate that you have tried and failed the plan's preferred step one alternative. The record does not indicate that you have 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. The requested service cannot be 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 Abraxane have not been met. Therefore, we decided that the Plan does not have to pre-approve Abraxane.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physical therapy services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the physical therapy services. You say that the enrollee is not able to go to other offices due to transportation difficulties. The Plan denied your request. The Plan says medically necessary services are available in-network at a comparable distance to the requested OON provider.
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 the physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neurolysis facet nerve injection.
You asked the Plan to pre-approve a neurolysis facet nerve injection. You say that the services are 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 an initial thermal radiofrequency ablation (RFA) of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary when specific criteria are met. 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 neurolysis facet nerve injection.
Our reviewer says that the services are not medically necessary. Our physician reviewer found the record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not 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 a neurolysis facet nerve injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a neurolysis facet nerve injection.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 home health physical therapy (PT) visits.
You asked the Plan to pre-approve 12 home health PT visits. You say that the services 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 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.
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 12 home health PT visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review has determined that the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 12 home health PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 home health physical therapy (PT) visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal surgery.
You asked the Plan to pre-approve a spinal surgery. You say that the services 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. 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 a spinal surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the elements of the coverage criteria are not satisfied. The requested service cannot be 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 a spinal surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal surgery.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from May 18, 2021, through May 21, 2021.
You asked the Plan to pay for the self-administered drugs. You say that it wasn't mandatory that you take these pills. You say that if you had known how much they cost you wouldn't have taken them. The Plan denied your request. The Plan says these drugs aren't covered under your medical 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 pay for the self-administered drugs provided from May 18, 2021, through May 21, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage criteria have not been met.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 30 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0481 provided on September 14, 2020.
You asked the Plan to pay for the drug testing. 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 payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code G0481 for the drug testing is a column II code to column I code G0483. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0481 provided on September 14, 2020.