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

 We decided that the Plan does not have to pre-approve a lumbar laminectomy to be provided by an out-of-network provider.  You asked the Plan to pre-approve the lumbar laminectomy. You say that the services are medically necessary. The Plan denied your request. The Plan says there are network providers available who can perform this procedure.  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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a lumbar laminectomy to be provided by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a computed tomography (CT) scan provided on May 20, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for CT scan. You say that when the enrollee was scheduled, only Original Medicare information was provided and the enrollee's family indicated that she no longer had this Plan. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.  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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  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 a computed tomography (CT) scan provided on May 20, 2021 by an out-of-network (OON) provider.
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 appears to be improving and should only require short term additional acute care hospital that can be safely administered at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered when treatment has completed.  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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Evenity for the enrollee  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 that the enrollee does not have any stated contraindications to the preferred products.  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 Evenity is not medically reasonable and necessary for the enrollee. The patient has not tried and failed Prolia or zoledronic acid. There is no documentation provided indicating that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Evenity.  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 for the enrollee
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 need this to correct a height difference between your legs. 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an air purifier.  You asked the Plan to pre-approve air purifier. You say that you really need this and cannot breathe without it. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because an air purifier does not meet the definition of durable medical equipment and is not covered.  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 an air purifier.
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 appears to be unstable at this time and should only require short term additional acute care hospital to further stabilize that can be safely administered at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered when treatment has completed and the enrollee is more stable.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the cardiology visit and related services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the cardiology visit and related services. You say that the provider is too far for you to travel because you cannot ride in a car for that long. 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 services at issue are urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the cardiology visit and related services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for a tissue exam provided on June 11, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the tissue exam. You say that the enrollee visited a participating facility, and you should not be penalized. The Plan denied your request. The Plan says no prior authorization was obtained.  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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.    The requested provider in this case is not a network provider with the Plan. 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. The record shows the facility is out-of-network. Therefore, we decided that the Plan does not have to pay for the tissue exam provided on June 11, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (85060) provided on July 8, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is 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.  We find that CPT code 85060 is not supported in the medical record. Specifically, code 85060 is assigned a PC/TC indicator of "8." This means that no payment is recognized for code 85060 furnished to hospital outpatients or non-hospital patients. The services in this case were billed with an outpatient hospital place of service. 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 the services (85060) provided on July 8, 2021.
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 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 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 have stabilized medically and are ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. You are 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 SNF. You do not have any parental medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near your baseline and you 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 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: Favorable

 We decided that the Plan has to pre-approve use of Botox.  You asked the Plan to pre-approve Botox. 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 the Plan requires a trial of Xeomin before it will approve Botox.  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. Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit a full copy of the applicable 2021 Evidence of Coverage for this enrollee, nor did the Plan submit an excerpt from the 2021 Evidence of Coverage which shows that the enrollee's contract with the Plan has implemented step therapy criteria for Medicare Part B prescription drugs. The Plan submitted a copy of a Medicare Part B preferred drug list; however, there is no evidence that this preferred drug listing is a binding element of the enrollee's contract with the Plan. Without this information, we cannot determine that the enrollee's contract with the Plan has implemented step therapy criteria which would require the enrollee to try and fail - or otherwise be contraindicated to use of - Xeomin before using the requested drug of Botox. Therefore, we decided that the Plan has to pre-approve use of Botox.   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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device (E0601), provided on June 25, 2020.  You asked the Plan to pay for the CPAP device. You say that you need this item. The Plan denied your request. The Plan says you obtained this item through a provider who is not certified with Medicare.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device (E0601), provided on June 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the unspecified preventive service (D1999), gingivectomy or gingivoplasty (D4211), and 2D oral or facial photographic images (D0350 x 3) provided on July 14, 2021.  You asked the Plan to pay for the dental services. You say that you were told before you received the services that they would be covered. You say that you received a letter on July 26, 2021, that the provider was no longer in network. You also say that you feel you should not be responsible for this bill due to the information you receivd before you received the services. The Plan denied your request. The Plan says the unspecified preventive service, gingivectomy or gingivoplasty, and the 2D photographic images are not listed as covered services.  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 unspecified preventive service, gingivectomy or gingivoplasty, and the 2D photographic images are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified preventive service (D1999), gingivectomy or gingivoplasty (D4211), and 2D oral or facial photographic images (D0350 x 3) provided on July 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee.  You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery has not been demonstrated in the peer-reviewed literature.  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 requested services are not considered medically reasonable and necessary in this case. Bone marrow aspirate remains experimental for use in spine surgery. More research is needed. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.  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 bone marrow aspirate for the enrollee.
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 stay is medically necessary. The Plan denied your request. The Plan says your record does not show that you require daily skilled nursing or skilled therapy in a SNF setting. The Plan states the services you require are called custodial care. The Plan states custodial care helps you with daily needs such as dressing, bathing, getting in and out of bed, going to the bathroom, and eating. The Plan states custodial care is not a covered benefit under Medicare or the Plan.  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 the required daily skilled services cannot be justified on an inpatient bases the additional treatment services can be safely received in non-inpatient settings and can be closely coordinated with home health care services. There is no medical necessity for specialized inpatient skill based on the review of the case. The Medicare criteria for SNF has four criteria and all of them must be fully satisfied to be eligible for inpatient SNF. You do not meet the criteria for daily skilled inpatient SNF as per the Medicare guidelines which clearly requires all the four criteria to be met. Putting you into inpatient SNF can potentially risk your health by exposing the patient to futile medical care and risk of inpatient infections.  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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (88342) provided on February 24, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.    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 88342 is a column II code to column I code 88188. 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 services (88342) provided on February 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for venography (75822-XU) provided on March 11, 2021.  You asked the Plan to pay for venography. You say that this was billed correctly. The Plan denied your request. The Plan says this is not separately 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. Providers should not report the 2 codes together if they're performed at the same anatomic site and same patient encounter, because they aren't considered "separate and distinct." Providers should not use modifiers 59 or -XU to bypass a PTP edit based on the 2 codes being "different procedures." In this case, we have confirmed that code 75822 is a column II code to column I code 37238. Although code 75822 was billed with modifier -XU, the records do not support the use of this modifier to bypass the edit because these services were performed at the same anatomic site and same patient encounter. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for venography (75822-XU) provided on March 11, 2021.