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

We decided that the Plan does not have to pre-approve an out-of-network referral for continuation of care with
plastic surgery.

You asked the Plan to pre-approve the referral. You say that you have been a patient of this provider, and you
are comfortable with their work. The Plan denied your request. The Plan says there are participating providers
available.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan
providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you
must use contract providers for care.

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 referral. Our reviewer says that the
requested continuation of care is not medically reasonable or necessary. Our physician reviewer found the
record indicates that the enrollee has a history of breast cancer and is seen by cancer doctors in network at the
same hospital. The provided records do not indicate the medical necessity or reasonableness, as defined by
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the referral have not been met. Therefore, we decided that the Plan does not
have to pre-approve an out-of-network referral for continuation of care with plastic surgery.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device  You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there appears to be some concern that the devices are not as effective as surgical decompression, and could lead to higher rates of reoperation.  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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee indicates that the enrollee has  chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The record indicates that the enrollee has a body mass index of 41. The record indicates that the enrollee has multi-level disease but does not document that the enrollee is not indicated for operative intervention at no more than two levels. The record includes an MRI from 2018 and secondary source documentation of one in December 2020. The record indicates that the enrollee has underwent a minimally invasive lumbar decompression at L2-3 and L4-5.   The requested service is for the L4-L5 level which according to the plan has been decompressed. The elements of the coverage criteria are not satisfied.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve adding the drug Durvalumab to the drug regimen of Cisplatin and Gemcitabine.  You asked the Plan to pre-approve Durvalumab. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the addition of Durvalumab is not medically necessary and reasonable at this time.  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 Durvalumab. Our reviewer says that the requested addition of Durvalumab is not medically reasonable and necessary. Our physician reviewer found the enrollee has been diagnosed with cholangiocarcinoma. The request is to add Durvalumab to the combination already being administered Cisplatin and Gemcitabine. The requested addition of Durvalumab is not FDA-approved for the enrollee's diagnosis. In addition, although TOPAZ-1 is a study showing efficacy of adding Durvalumab to Cisplatin and Gemcitabine, it appears in abstract form only and does not meet level evidence as required by Medicare 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 Durvalumab have not been met. Therefore, we decided that the Plan does not have to pre-approve adding the drug Durvalumab to the drug regimen of Cisplatin and Gemcitabine.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing (CPT code G0481) provided to the enrollee on June 4, 2021, by a non-participating laboratory.  You asked the Plan to pay for the drug testing. You say that the test is deemed medically necessary for the treatment and management of pain for this enrollee. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.  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 the drug testing (CPT code G0481) provided to the enrollee on June 4, 2021, by a non-participating laboratory.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Otezla (J8499).  

You asked the Plan to pre-approve Otezla. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.    

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 Otezla (J8499).   

Benefits for Otezla 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that the enrollee will clearly benefit from acute rehabilitation to optimize their level of functioning prior to returning home. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states the enrollee can safely receive the services they need in other settings, for example: a skilled nursing facility.  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 was admitted for respiratory failure and Coronavirus (COVID-19) pneumonia. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the endodontic therapy services received on July 2, 2021.  You asked the Plan to pay for the endodontic therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.  Medicare generally does not cover dental services. The Plan follows the same rule.  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 endodontic therapy services received on July 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.  You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the continuation of skilled services can be provided on an intermittent basis in an outpatient 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. Continued SNF care beyond February 10, 2022, was requested. 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 continued services. Our physician reviewer found that you were admitted to the skilled nursing facility after treatment for a transient ischemic attack. You are walking with standby assistance using a rolling walker. You were at a supervision assist level for transfers and minimum assist for activities of daily living. There is no documentation that you require skilled nursing services of a skilled professional nurse to provide medically necessary treatment. Although there are skilled therapy needs, you do not require skilled nursing or therapy services on a daily basis in a SNF 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Cxbladder testing rendered on August 19, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered.  We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on August 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a LDCT scan for lung cancer screening.  You asked the Plan to pre-approve the requested LDCT scan. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you previously completed a LDCT screening on July 20, 2021.    The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.   We reviewed the file and the Medicare rules. We find that you previously had a LDCT screening on July 20, 2021, so the annual benefit is exhausted at this time. Therefore, we decided that the Plan does not have to pre-approve a LDCT scan for lung cancer screening.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the non-sterile gloves.

You asked the Plan to pre-approve the non-sterile gloves. You say that you need gloves for catheter changes. The Plan denied your request. The Plan says Medicare does not cover non-sterile gloves.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

Medicare do not cover non-reusable disposable supplies for home use, such as bandages, gauze, tape, antiseptics or dressings. Medicare does not cover non-sterile gloves. Therefore, we decided that the Plan does not have to pre-approve the non-sterile gloves.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmological exams (92012,
92083, 92004) provided from August 11, 2021, to September 7, 2021.

You asked the Plan to waive the copayment for the eye exams. You say that you are receiving $40 bills for
these services, but you should have a $0 copayment for glaucoma screenings. The Plan denied your request.
The Plan says these claims were processed correctly, and your copayments were assessed in accordance with
your contract. You are responsible for a $40 copayment for physician services to diagnose and treat diseases
and conditions of the eye.

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 $40
copayment for physician services to diagnose and treat diseases and conditions of the eye.

You have been asked to pay a $40 copayment for each of the three eye exam appointments. The services in
question were not billed as screening services, and the record indicates that you were diagnosed with glaucoma
some years ago. A screening is a regular check-in that is provided for a patient that has no known symptoms or
cause for concern. If a patient has symptoms or a medical history of a certain condition, the care provided is
considered diagnostic. Because you have a history of glaucoma, the eye exams you received would not be
considered screenings, and instead fall within the physician services to diagnose and treat diseases and
conditions of the eye benefit category. This means that you have been asked to pay the 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 the ophthalmological
exams (92012, 92083, 92004) provided from August 11, 2021, to September 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81225, 81226, 81227, 81230, 81231, 81232, 81355, 81381, 81381-59, 81240, 81241, 81283, 81328, 81335, 81350) provided to the enrollee on August 23, 2021.  You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  If one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. If no CPT code accurately describes the procedure performed, the laboratory may report CPT code 81479 (Unlisted molecular pathology procedure) with one unit of service or may report multiple individual CPT codes describing the component test results when medically reasonable and necessary. Procedures reported together  must be both medically reasonable and necessary (e.g., sequencing of procedures) and ordered by the physician who is treating the beneficiary and using the results in the management of the beneficiary's specific medical problem. Therefore, the procedure codes billed are not correct/valid for the services billed or the date of service billed. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81225, 81226, 81227, 81230, 81231, 81232, 81355, 81381, 81381-59, 81240, 81241, 81283, 81328, 81335, 81350) provided to the enrollee on August 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a knee orthosis.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that a knee orthosis is covered 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has knee pain due to chronic arthritis. The records do not clearly show objective knee instability, recent surgery, or other indication to justify a knee brace at this time. Therefore, the knee orthosis 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services provided by an out-of-network provider on July 14, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.  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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.  Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the puncture aspiration services (10160) provided on May 12, 2021, and billed with the -78 modifier.  You asked the Plan to pay for the puncture aspiration services. You say that the procedure did not return to the operating room to accommodate the patient. The Plan denied your request. The Plan says the claim has not been billed in accordance with Medicare coding regulations.  The Plan must follow Medicare rules. Medicare rules say that physicians report modifier 78 during the global surgery post-operative period for services that required a return to the operating room.  We looked at the file and Medicare rules. In this case, the record indicate that the patient did not have these services performed in the operating room as required by the billing of modifier -78. Based on this information, we decided that Medicare rules for coverage of the puncture aspiration services have not been met. Therefore, we decided that the Plan does not have to pay for the puncture aspiration services (10160) provided on May 12, 2021, and billed with the -78 modifier.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the brain for the enrollee.  You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says repeat imaging is not supported without results of prior imaging that show a need for it.  The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found the enrollee has had third ventriculostomy for hydrocephalus. The last MRI was 11/30/21, which showed no appreciable change with stable ventricular size since 10/15/20. There is no clinical documentation explaining the reason for the medical necessity of MRI so soon after an exam less than three months ago.    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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the brain for the enrollee.