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

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. 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.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat.
You asked the Plan to pre-approve a raised toilet seat. You say that you are having difficulty standing in shower and sitting on the toilet. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat may be appropriate for you, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for knee arthroscopy (29875) provided on May 4, 2021.
You asked the Plan to pay for knee arthroscopy. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 29875 is inclusive to the primary procedure code 29871.
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 29875 is arthroscopy, knee, surgical; synovectomy, limited (e.g., plica or self resection) (separate procedure). We asked our coder 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 knee arthroscopy.
Our reviewer says that this code does not meet the criteria for payment. Our reviewer found you billed code 29875 with modifier -59 (distinct procedural service); however, the documentation does not support this procedure as a distinct separate procedure from the primary service reported. Modifier -59 should distinguish a different session or patient encounter, a different procedure or surgery, different anatomical site, or separate surgery. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee arthroscopy have not been met. Therefore, we decided that the Plan does not have to pay for knee arthroscopy (29875) provided on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that you were told your primary care doctor was in-network and you do not want to change doctors. The Plan denied your request. The Plan says the provider is out-of-network.
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 office visit to be provided by an out-of-network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that the services should be covered. The Plan denied your request. The Plan says there is no documentation to support the expectation that the enrollee will require a greater than 2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the planned procedure listed under Current Procedural Terminology (CPT) codes 63047 and 63048 are not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator electrode array (63650).
You asked the Plan to pre-approve the neurostimulator. You say that the service should be covered.
The Plan denied your request. The Plan says the neurostimulation is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that dorsal column stimulators may be covered as therapies for the relief of chronic intractable pain under certain circumstances. 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 neurostimulator. Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation shows that the enrollee has tried physical therapy, injections, medications, although documented record of these as well as surgical evaluation were not provided to clearly show full exhaustion of other treatment options. Based on there being insufficient documentation of this being a last resort and as the records not showing evidence of spinal cord injury, this request for neurostimulation will be considered not 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 the neurostimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator electrode array (63650).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the enrollee cannot tolerate sitting upright in his chair. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism.
You asked the Plan to pre-approve a seat lift mechanism. You say that the records and prescription provided support the need for a seat lift mechanism. The Plan denied your request. The Plan says they do not have documentation of an in-home assessment. The Plan says that, without this, they cannot assess the enrollee's mobility. The Plan says that there is no evidence that the enrollee is unable to safely sit and stand from any chair in their home. The Plan says that there is no evidence that the enrollee has swelling in her legs or that she would be able to use the chair safely and independently.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section 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 seat lift mechanism. Our reviewer says that the criteria for coverage have not been met.
Our physician reviewer found the enrollee has diffuse arthritis, as well as neuropathy related to diabetes. The records do not clearly include a seat lift mechanism in the treating practitioner's treatment plan. The records do not clearly address the seat lift mechanism with regard to improving the patient's condition or arresting deterioration in the patient's condition. The records do not clearly show that the patient is completely incapable of standing from a chair in the home. A physical therapy assessment from June 3, 2021 reports that she can transfer sit to stand with minimum to moderate assistance. 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 seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that you are having difficulty standing in shower and sitting on the toilet. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva.

You asked the Plan to pre-approve the Xgeva. You say that the drug is necessary. The Plan denied your request. The Plan says their reviewer found this request did not meet the Plan's Part B step therapy criteria for Xgeva.

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 Xgeva. Our reviewer says that the service is not medically necessary. Our physician reviewer found the Plan requires a trial of pamidronate or zoledronic acid before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the 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 the Xgeva have not been met. Therefore, we decided that the Plan does not have to pre-approve Xgeva.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexilant.
You asked the Plan to pre-approve Dexilant. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Dexilant.
Benefits for Dexilant 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.

You asked the Plan to pre-approve a portable ventilator. You say that the 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 that ventilators (E0465, E0466, and E0467) are covered for the certain conditions. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a portable ventilator. Our reviewer says that the item is not medically necessary. Our physician reviewer found the documentation supports that the enrollee has chronic respiratory failure consequent to chronic obstructive pulmonary disease (COPD). Products currently classified as HCPCS code E0466 when used to provide continuous positive airway pressure therapy (CPAP) or bi-level positive airway pressure therapy (PAP) (with or without backup rate) therapy, regardless of the underlying medical condition, shall not be paid in the FSS payment category. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal electrical osteogenesis stimulator.
You asked the Plan to pre-approve the bone growth stimulator. You say that the bone growth stimulator should be covered. The Plan denied your request. The Plan says the records do not indicate the enrollee meets the coverage criteria.
The Plan follows Medicare rules. Medicare rules say that there was a failed spinal fusion greater than nine months ago, a multilevel spinal fusion surgery, or spinal fusion surgery where there is a history of a previously failed spinal fusion at the same site. 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 bone growth stimulator. Our reviewer says that the service is not medically necessary.
Our physician reviewer found the documentation does not show the fusion surgery was on 3 more vertebrae or that you have had a prior failed fusion of the same bones. 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 bone growth stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal electrical osteogenesis stimulator
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implantation of neuro-electrodes to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the implantation of neuro-electrodes. You say that the service is not investigational and is medically necessary. The Plan denied your request. The Plan says the provider is out-of-network.
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. The records provided for review do not show that the service at issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the implantation of neuro-electrodes to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that that it would not be safe for the enrollee to return home alone. You say that staying the hospital would put the enrollee at increased risk of infection and also increase immobilization. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the enrollee can receive the care needed in another setting.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehabilitation services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. She is medically stable without any acute exacerbations of chronic medical problems. Her physical function is at or near her baseline and she can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefabricated stainless-steel crown represented by code D2931.

You asked the Plan to pre-approve a prefabricated stainless-steel crown. You say that you need the requested prefabricated stainless-steel crown to restore a decaying tooth. You say that you had the same procedure denied in 2020, but that it was overturned on appeal. The Plan denied your request. The Plan says prefabricated stainless-steel crowns are not a covered benefit.

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 prefabricated stainless-steel crown represented by code D2931.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation and the office visits to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the consultation and the office visits. You say that you were recently diagnosed with breast cancer and would like to seek a second opinion. The Plan denied your request. The Plan says the provider is out-of-network.

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 consultation and the office visits to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing services.
You asked the Plan to pre-approve the skilled nursing services. You say that the services are medically necessary. The Plan denied your request. The Plan says the documentation does not show that the enrollee requires daily skilled nursing or therapy in a SNF setting.
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 the skilled nursing services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation that the patient requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing services.