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

We decided that the Plan does not have to pay for the DecisionDx-Melanoma test provided to the enrollee on April 22, 2021.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says the medical necessity of this test has not been established.
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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found various (mostly retrospective) studies of prognostic gene expression profiling (GEP) testing suggest its role as an independent predictor of worse outcome, though not superior to Breslow thickness or sentinel lymph node (SLN) status. It remains unclear whether DecisionDx Melaona, a GEP, is reliably predictive of outcome across the risk spectrum of melanoma. Prospective validation studies (as have been performed in breast cancer) are required to more accurately define the clinical utility of molecular testing prior to widespread implementation of GEP for prognostication of cutaneous melanoma, and in particular to determine its role in guiding surveillance imaging, sentinel lymph node biopsy, and adjuvant treatment decisions. Existing and emerging GEP platforms and other prognostic techniques should also be compared with optimized contemporary multivariable phenotypic models. The service 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 the testing have not been met. Therefore, we decided that the Plan does not have to pay for the DecisionDx-Melanoma test provided to the enrollee on April 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for screening mammography (77067-TC) providing July 26, 2021.
You asked the Plan to pay for the diagnostic service. You say that the enrollee had multiple exams on this date of service. Attached reports to support level of service. Please reconsider for processing. The Plan denied your request. The Plan says the submitted documentation supports 1 unit of 77067-TC, which was approved.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 77067 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for screening mammography (77067-TC) providing July 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure 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 there is little evidence in the medical literature to suggest that this is an appropriate procedure for the enrollee's back pain.
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. The intracept procedure is experimental. More research is needed to show safety and efficacy. 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 the Intracept procedure for the enrollee.
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 need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from physical therapy, and occupational therapy, the enrollee's rehab needs can be safely provided in an alternate and lower intensity setting such as in a skilled nursing 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an incision and drainage of abscess (10060) provided on December 21, 2020.
You asked the Plan to waive the copayment for an incision and drainage of abscess. You say that the applied copayment exceeds what is normal for a doctor office visit. The Plan denied your request. The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for each Medicare-covered outpatient hospital facility visit. You have been asked to pay $175.88 for an incision and drainage of abscess. An incision and drainage of abscess falls within the "Outpatient surgery" benefit category. This means that you have been asked to pay less than or equal to the full and correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for an incision and drainage of abscess (10060) provided on December 21, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90834) provided on July 29, 2021.

You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90834) provided on July 29, 2021.
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 this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is being prescribed for an off-label indication and is not eligible for coverage.

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 Prolia. Our reviewer says that the requested drug is not medically necessary for the enrollee's condition. Our physician reviewer found the enrollee is an 84 year old man diagnosed with metastatic prostate cancer. In this case, Prolia is not being prescribed for the enrollee's condition. The LCD requires that the enrollee's prostate cancer be non-metastatic for Prolia to be covered. Xgeva is more appropriate for bone metastases. Finally, the use of this drug 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 Prolia have not been met. 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 pay for infection control supplies provided to the enrollee on July 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 these codes are not valid for Medicare purposes.
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 the denied codes is:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on August 25, 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 an appropriate modifier was not billed in this case.

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 77001 is a column II code to column I code 20982. 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 imaging services provided to the enrollee on August 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 18, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.

The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the
laboratory services provided on June 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that records do not show that the enrollee requires care that can only be given in the hospital setting.
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. The patient is improving and should only require short-term additional acute care services that can be safely administered at the current facility until appropriate for a lower level of care. The patient does not require services at the LTACH that are not already available and covered at the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a continuous glucose monitor (CGM) provided
to the enrollee on January 1, 2021.
You asked the Plan to provide coverage for a continuous glucose monitor. You say that this claim should be
paid. The Plan denied your request. The Plan says Medicare coverage criteria for a continuous glucose monitor
were not met. We overturned the Pans denial. The Plan requested a reopen and stated that we did
not apply the correct coverage criteria.
The Plan states that Medicare rules, based on the Medicare LCD therapeutic CGMs are considered medically
reasonable and necessary for members with diabetes who use insulin with a least three daily injections, perform
frequent (four or more times a day) testing, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results. The medical records and documentation submitted do not reflect these
criteria are met. Therefore, the records provided did not support the services billed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare requires all of the criteria listed
in the Medicare rules be met for this type of equipment to be covered. The medical records provided do not
clearly show all of these criteria were met at the time of service. Therefore, we decided that the Plan does not
have to provide coverage for a continuous glucose monitor (CGM) provided to the enrollee on January 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Feraheme.

You asked the Plan to pre-approve Feraheme. You say that these services are medically necessary. The Plan denied your request. The Plan says that you have not tried and failed the preferred step therapy drugs.

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 Feraheme. Our reviewer says that Feraheme is not medically reasonable and necessary. You have not clearly failed maximum dosing of oral iron supplementation and have not tried and failed other IV iron therapies that are covered by the Plan, namely Venofer or Infed which are equivalent to the Faraheme in effectiveness and safety. The formulary options would not be less effective or lead to more adverse effects compared to Faraheme. Our physician reviewer found that your condition does not meet step therapy criteria for Feraheme. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have to pre-approve Feraheme.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve push handles (K0108) for the approved ultralight manual wheelchair.
You asked the Plan to pre-approve push handles. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says push handles are a non-standard upgrade and do not primarily serve a medical purpose.
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 push handles (K0108) for the approved ultralight manual wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit for the enrollee.

You asked the Plan to pre-approve Retacrit. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the drug is not being prescribed for a medically accepted indication.

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 Retacrit. Our reviewer says that Retacrit is not medically reasonable and necessary for the enrollee. Retacrit is not FDA-approved for the enrollee's diagnosis as her most recent hemoglobin is greater than 10 at 11.5. The use of Retacrit is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Retacrit.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical supplies (99072, S8301, A9901, A4649, A4550)
provided December 23, 2020.
You asked the Plan to pay for the medical supplies. You say that the services were medically necessary. The
Plan denied your request. The Plan says the codes billed are 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.
We find that CPT codes 99072, S8301, A9901, A4649, and A4550 are not supported in the medical record.
Specifically, the billed codes have a status of "B" per the National Physician Fee Schedule. Payment for these
items is included in payment for the primary service. Based on this information, we decided that Medicare rules
for coverage of the medical supplies have not been met. Therefore, we decided that the Plan does not have to
pay for medical supplies (99072, S8301, A9901, A4649, A4550) provided December 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7210), limited oral evaluation (D0140) and periapical x-ray (D0220) provided on September 2, 2021.
You asked the Plan to pay for the dental services. You say that the claim was denied stating a narrative was needed. You also say that the services were necessary. The Plan denied your request. The Plan says the services you received are not covered by the Plan or Medicare
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, dental services performed out of network are not among those covered under this benefit. Additionally, the services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the extraction (D7210), limited oral evaluation (D0140) and periapical x-ray (D0220) provided on September 2, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have 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 the beneficiary is a 77 year old male with left facial fracture after fall dementia with behaviors, acute sialadenitis, chronic kidney disease, and diabetes. In this case, there are no identifiable skilled nursing service needs and there are no identifiable skilled therapy service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis. In conclusion, this beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

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 admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Omnipod Dash 5 pack.
You asked the Plan to pre-approve the Omnipod Dash 5 pack. You say that you would like reconsideration because the requested supplies are medically necessary. The Plan denied your request. The Plan says drug coverage is limited only to those drugs covered under your medical benefit.
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems are non-covered devices because they do not meet the Medicare definition of durable medical equipment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Omnipod Dash 5 pack have not been met. Specifically, the Omnipod Dash is a disposable drug delivery system that is not covered under Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Omnipod Dash 5 pack.
Benefits for the Omnipod Dash 5 pack may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.