Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 15 physical therapy visits in your home, 15 minutes each (G0151).  You asked the Plan to pre-approve home health services. You say that the requested visits are medically necessary. The Plan denied your request. The Plan says the requested services are not medically necessary.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 home health services. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found the documentation does not support that the enrollee requires additional skilled rehabilitation (rehab) services to provide treatment that is medically necessary. The reviewer found that the enrollee does not require additional skilled rehab services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The reviewer found that the enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Therefore, the reviewer found that the requested home health services are 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 home health services have not been met. Specifically, the file does not indicate that the enrollee does not require additional skilled rehabilitation services. Therefore, we decided that the Plan does not have to pre-approve 15 physical therapy visits in your home, 15 minutes each (G0151).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve neurologic/neuropsychological assessment testing.  You asked the Plan to pre-approve neurologic/neuropsychological testing. You say that the enrollee needs to be evaluated to determine the best care. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this testing is not medically necessary.  The Plan follows Medicare rules. Medicare rules state that neuropsychological assessment tests may be covered under certain circumstances.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve neurologic/neuropsychological testing.   Our reviewer says that the enrollee does not meet the Medicare criteria for the requested neuropsychological assessment. Our physician reviewer found the enrollee has been having difficulties with cognitive impairment, sensory, or motor limitations including hearing, vision, and tremor, unexpected deficits in reception for expressive language, and behavioral abnormalities. You are requesting an excessive amount of this procedure beyond what is approved by Medicare. There is no documentation that justifies the extra amount of time in the testing and assessment.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neurologic/neuropsychological testing have not been met. Therefore, we decided that the Plan does not have to pre-approve neurologic/neuropsychological assessment testing.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Velcade (J9041) Dexamethasone sodium phosphate (J1100).  You asked the Plan to pre-approve Velcade Dexamethasone sodium phosphate. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy requirements have not been met.  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 Velcade Dexamethasone sodium phosphate. Our reviewer says that the requirements for coverage of Velcade Dexamethasone sodium phosphate have not been met. Our physician reviewer found the Plan requires a trial of generic bortezomib intravenous before they will approve the requested drug. The enrollee has not tried and failed the required drug. There is no documentation provided indicating that the plan's required drug would likely be less effective or have adverse effects for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Velcade Dexamethasone sodium phosphate have not been met. Therefore, we decided that the Plan does not have to pre-approve Velcade (J9041) Dexamethasone sodium phosphate (J1100).
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

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 patient does not require LTACH services that are not already available at the current 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 the LTACH services have not been met. Specifically, medically necessary services can be obtained in a lower level of care. This means LTACH admission is not medically necessary or reasonable. 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 Supartz.  You asked the Plan to pre-approve Supartz. The Plan denied your request. The Plan says imaging showed normal bone with no documented osteoarthritis.  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.   The file shows that Supartz injections for the right and left knee were requested. The Plan has agreed to pre-approve an injection for the left knee. 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 Supartz for the right knee. Our physician reviewer found that the enrollee has bilateral knee pain due to osteoarthritis of the knee. Intra-articular injections with hyaluronic acid (Supartz) are recommended as a possible option for severe osteoarthritis for those who have not responded adequately to recommended conservative treatments. In this case, there is no documentation that the enrollee has osteoarthritis of the right knee. The documentation does not support that the Supartz is medically reasonable or necessary for this enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural injection.

You asked the Plan to pre-approve lumbar epidural injection. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this is not medically necessary.

The Plan follows Medicare rules. Medicare rules state that epidural steroid injections may be covered if certain 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 lumbar epidural injection. Our reviewer says that the enrollee meets the Medicare criteria for the requested lumbar epidural injection. Our physician reviewer found there is no documentation that the enrollee has radicular symptoms. There is also no documentation that he has been evaluated by his physician or staff since September 2021, prior to magnetic resonance imaging (MRI) being done. In addition, this request is for an epidural steroid injection at an unspecified level.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar epidural injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a genicular nerve block.  You asked the Plan to pre-approve the requested services. You say that you have severe pain in both knees. The Plan denied your request. The Plan says the service is considered investigational.  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 requested services. Our physician reviewer found that you have chronic bilateral knee pain, mild to moderate degenerative joint disease, left greater than right.    You have been seen by an orthopedic surgeon and have received steroid injections as well as viscous supplement injections. Genicular nerve blocks and genicular nerve radiofrequency ablations are considered investigational for the treatment of chronic knee pain. Therefore, the requested blocks 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Intracept intraosseous nerve ablation system.  You asked the Plan to pre-approve Intracept intraosseous nerve ablation system. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.  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 Intracept intraosseous nerve ablation system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has longstanding back pain. The Intracept procedure is experimental. More research is needed to show safety and efficacy. Therefore, the enrollee does not meet criteria for the requested 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 Intracept intraosseous nerve ablation system have not been met. Therefore, we decided that the Plan does not have to pre-approve Intracept intraosseous nerve ablation system.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit provided on April 13, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit. You say that this procedure was performed out of necessity to best treat the enrollee. The Plan denied your request. The Plan says enrollees are required to see in-network providers.   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 an office visit provided on April 13, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve Trastuzumab.  You asked the Plan to pre-approve Trastuzumab. You say that the enrollee is out of standard of care options. The Plan denied your request. The Plan says that the request is not considered medically necessary based on the current literature.  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 Trastuzumab. Our physician reviewer found that the enrollee has overexpressing biliary cancer. The requested use of the drug is not FDA-approved for the enrollee's diagnosis. However, the use is supported by an approved medical journal, The Lancet Oncology, volume 22, issue 9. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Trastuzumab have been met. Therefore, we decided that the Plan has to pre-approve Trastuzumab.   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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the electrocardiogram (CPT code 93010) provided to the enrollee on May 31, 2021.  You asked the Plan to pay for the electrocardiogram. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram have not been met. Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 99152 and 93010.   This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. Therefore, we decided that the Plan does not have to pay for the electrocardiogram (CPT code 93010) provided to the enrollee on May 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide additional payment for the determination of refractive state (92015) and office or other outpatient visit for the evaluation and management of an established patient (99214) provided July 16, 2021.  You asked the Plan to provide additional payment for the medical eye refraction and office visit. You say that these services are necessary and should be covered. The Plan denied your request. The Plan says the claims have been processed correctly.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers Medicare-covered vision services provided at a specialist's office with a $50 copayment. The Plan covers eye refractions when provided as part of a routine eye exam.   We looked at the file and the Plan's rules. You have been asked to pay a $50 copayment for the office visit. This service falls within the vision services benefit category. This means you have been asked to pay the correct amount based on your contract with the Plan. In this case the eye refraction was performed as part of a medical vision appointment. The Plan only covers eye refractions as part of a routine eye exam. Therefore, the eye refraction is not covered under your benefits. Therefore, we decided that the Plan does not have to provide additional payment for the determination of refractive state (92015) and office or other outpatient visit for the evaluation and management of an established patient (99214) provided July 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous glucose monitor supplies provided on June 20, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says supplies are not reportable before the expiration of the last month supply period.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   Continuous glucose monitor supplies were billed for services on June 20, 2021. We looked at the file and the rules. The records show that supplies were previously billed on the date of service at issue. No more than 1 unit of service of code K0553 is billable per 30 days. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor supplies provided on June 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for a bladder cancer screening (88120) provided on February 24, 2021.  You asked the Plan to pay for a bladder cancer screening. You say that this is supported in the records. The Plan denied your request. The Plan says this is not a covered screening service.  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 test at issue in this appeal, a bladder cancer screening, 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 a bladder cancer screening (88120) provided on February 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical preparation services billed for services provided on May 18, 2021.  You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code cannot be verified.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 15004 is surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children.  We find that CPT code 15004 is not supported in the medical record. Based on this information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for surgical preparation services billed for services provided on May 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator (AED) provided on October 9, 2021.  You asked the Plan to waive the coinsurance for the AED. You say that the hospital staff informed you that the device would be covered, and you believed the provider was in-network. The Plan denied your request. The Plan says the correct coinsurance 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 15% coinsurance for each durable medical equipment (DME) item from an in-network provider.   You have been asked to pay $439.72, which is 15% of the allowed amount for the AED ($2931.45 allowed amount x 15% coinsurance = $439.72). The AED falls within the Durable Medical Equipment (DME) and Related Supplies 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 coinsurance for an automatic external defibrillator (AED) provided on October 9, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a colonoscopy with biopsy performed on August 24, 2021.  You asked the Plan to waive the copayment for the colonoscopy. You say that you have not had a copayment previously. 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 $200 copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility.   You have been asked to pay a $200 copayment for the colonoscopy. Please note that since the procedure included a biopsy, it is then considered a surgical procedure instead of a screening colonoscopy. Therefore, the colonoscopy 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 a colonoscopy with biopsy performed on August 24, 2021.