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

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that [the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled nursing or therapy services on a daily basis. 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 skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the dental services provided on August 26, 2021 and September 9, 2021.  You asked the Plan to pay for the dental services. You say that you were told the provider was listed as a contracted provider. You say that your dentures are on hold until the Plan pays for the claim. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.  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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided on August 26, 2021 and September 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  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 criteria for coverage are not met.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not does not treat with insulin three or more times per day. 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 continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve laser treatments coded as 96920, 96921 and 96922.  You asked the Plan to pre-approve laser treatments. You say that requesting approval for 30 treatments to accommodate the potentially required 12-week series and 6 additional maintenance treatments. The laser is FDA approved for the treatment of Vitiligo. The Plan denied your request. The Plan says the clinical documentation received do no support that you have psoriasis. Laser treatment for inflammatory skin disease is covered for the treatment of psoriasis.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We looked at the file, and Medicare rules. The health Plan contract says that laser treatment for inflammatory skin disease is covered for the treatment of psoriasis. Laser treatment is being requested for the treatment of Vitiligo. Based on this information, we decided that Medicare rules for coverage of laser treatments have not been met. Therefore, we decided that the Plan does not have to pre-approve laser treatments coded as 96920, 96921 and 96922.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the cataract surgery provided on January 25, 2021.  You asked the Plan to waive the copayment for the cataract surgery. You say that your first payment was refunded, and now you are being charged again. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  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 $180 copayment for each visit to an Ambulatory Surgical Center for surgical services.   You have been asked to pay a $180 copayment for the cataract surgery. The cataract surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 cataract surgery provided on January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on May 26, 2021.  You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration because there was not another service billed by this provider on the same date of service. The Plan denied your request. The Plan says CPT code 99233 denied because it is bundled to another service billed on the same day by a physician of the same specialty in the same billing group, which is considered the same provider.  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 99233 is a column II code to column I code 99222. CPT 99222 was billed by a physician in the same group with the same specialty on the same date of service. 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 subsequent hospital care (99233) provided on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve office visits to be rendered by the out-of-network (OON) provider.  You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested services.  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 office visits to be rendered by the out-of-network (OON) provider.
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 you had an infection and need to be in a better place. The Plan denied your request. The Plan says under Medicare, your request is not medically necessary.  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 that the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Evenity for the enrollee.  You asked the Plan to pre-approve Evenity. You say that this is medically necessary. The Plan denied your request. The Plan says that there are no medical reasons that prevent using a preferred drug.  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. Based on the medical records provided the patient has not tried and failed Prolia or Reclast. There is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the patient. 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient hospital care.  You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that 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 admission are met in this case. Our physician reviewer found the review has determined that the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care would span two midnights.  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 acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional skin barrier wipes.  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 additional ostomy supplies are covered when 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted documentation does not support that the enrollee meets the criteria for coverage of additional ostomy skin barrier wipes. There is no clinical information that documents factors requiring excess ostomy supplies beyond the maximum quantity. The additional 900 skin barrier wipes are 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional skin barrier wipes.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Opdivo.  You asked the Plan to pre-approve Opdivo. 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. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Opdivo. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the combination of nivolumab and ipilimumab is not FDA approved for subsequent line therapy of non-small cell lung cancer. The enrollee has also progressed on prior lines of therapy that included nivolumab and pembrolizumab. The use of subsequent immunotherapy would not be indicated. 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 Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve the computed tomography angiography (CTA).  You asked the Plan to pre-approve the CTA. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the requested CTA is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CTA. Our reviewer says that the requested CTA is medically reasonable and necessary. Our physician reviewer found the requested CTA is necessary in order to determine if anticoagulants may be discontinued.  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 CTA have been met. Therefore, we decided that the Plan has to pre-approve the computed tomography angiography (CTA).   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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost-sharing for the myocardial perfusion imaging (78452) and transthoracic echocardiogram (C8929) provided February 8, 2021.  You asked the Plan to waive the cost-sharing for the myocardial perfusion imaging and transthoracic echocardiogram. You say that the services were related to coronavirus (COVID-19) and you feel they should be covered in full. The Plan denied your request. The Plan says there is no evidence the services provided were related to COVID-19 and the copayment has been applied correctly.  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 advanced imaging service and 20% coinsurance for Medicare-covered diagnostic procedures and tests.  You have been asked to pay a $250 copayment for the myocardial perfusion imaging and 20% coinsurance for the transthoracic echocardiogram. The myocardial perfusion imaging and transthoracic echocardiogram falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. There is no evidence in the provided medical records showing that these services were directly related to COVID-19 and therefore the cost-shares do not appear to be eligible to be waived. 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 cost-sharing for the myocardial perfusion imaging (78452) and transthoracic echocardiogram (C8929) provided February 8, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pre-approve radiation therapy.  You asked the Plan to pre-approve radiation therapy. You say that the services are necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have not been met.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 radiation therapy. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found based upon the criteria outlined by the NCCN guidelines, and the enrollee's case meeting these criteria, it would seem reasonable that the treatment would be furnished in accordance with accepted standards of medical practice.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiation therapy have been met. Therefore, we decided that the Plan has to pre-approve radiation therapy.   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 pre-approve a Dexcom G6 sensor.  You asked the Plan to pre-approve a Dexcom G6 sensor. You say that the item is 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. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 a Dexcom G6 sensor. Our reviewer says that the item is not medically necessary. Our physician reviewer found in this case, the record indicates that you have diabetes and check your sugars three times daily. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 sensor.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the needle electromyography (95861 and 95869), somatosensory testing (95927 and 95938) and the evoked potential study (95939).  You asked the Plan to pay for the needle electromyography, somatosensory testing and evoked potential study. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the professional interpretation must be billed with modifier 26.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We find that CPT codes 95939, 95938, 95861, 95927 and 95869 are not supported in the medical record. Specifically, this claim was billed with an inpatient place of service code. Additionally, the codes at issue were billed with the TC modifier indicating that this is the technical component. Payment for the technical component of these services is included in the payment to the hospital and is the responsibility of the hospital to any vendor. Based on this information, we decided that Medicare rules for coverage of the needle electromyography, somatosensory testing and evoked potential study have not been met. Therefore, we decided that the Plan does not have to pay for the needle electromyography (95861 and 95869), somatosensory testing (95927 and 95938) and the evoked potential study (95939).