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

We decided that the Plan does not have to pre-approve Aranesp (J0881).

You asked the Plan to pre-approve Aranesp. You say that the requested drug is medically necessary for treatment of the enrollee's conditions. The Plan denied your request. The Plan says the enrollee has not tried and failed the require drug, Retacrit.

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 Aranesp. Our reviewer says that the request for Aranesp is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has tried and failed the preferred drug, Retacrit. The reviewer also found that the documentation does not support that Retacrit would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Therefore, the reviewer found that the requested drug is not medically necessary as the step therapy criteria has not been met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Specifically, the file shows that the enrollee has not tried and failed the required drug. Therefore, we decided that the Plan does not have to pre-approve Aranesp (J0881).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit (99337) provided on September 2, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a domiciliary or rest home visit. You say that this was medically necessary. The Plan denied your request. The Plan says this was 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit (99337) provided on September 2, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 pain management office visits to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the 4 OON pain management office visits. You say that you have back issues and could not get in to see a participating pain management provider until January 16, 2022. You say that instead of going to the emergency room you found an OON doctor to see you on December 29, 2021. You say that you were given Naproxen and Gabapentin. You say that this doctor wants to see you in another month to see whether the medication is helpful and told you to come back sooner if pain gets worse. You say that you are still having pain and need assistance, but that the stabbing pain in your leg is a bit better. You say that you want to continue seeing the provider who is currently treating you. The Plan denied your request.

The Plan says there is no medical need shown as to why the enrollee cannot get the pain management services from a provider within the plan network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve OON services. Therefore, we decided that the Plan does not have to pre-approve 4 pain management office visits to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90791, 90832) provided on May 6 to May 15, 2020.  You asked the Plan to pay for psychotherapy services. You say that the claims at issue are untimely due to Plan error. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  The record shows that a claim for psychotherapy services was not filed until July 22, 2021. This means that more than one calendar year from the dates of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90791, 90832) provided on May 6 to May 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided on July 28, 2021.  You asked the Plan to pay for the self-administered drugs. You say that you feel you should not be held liable for this payment because the medication was prescribed. The Plan denied your request. The Plan says the medications you received were self-administered and are not covered under your plan.  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 pay for the self-administered drugs provided on July 28, 2021.   Benefits for the self-administered drugs 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (0242U) provided on April 26, 2021.
You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the targeted genomic sequence analysis panel have not been met.
Specifically, the claim was billed with the laboratory place of service code while the records indicate that the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (0242U) provided on April 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 30.
You asked the Plan to pre-approve a crown for tooth # 30. You say that the requested crowns are necessary. The Plan denied your request. The Plan says a crown for tooth # 30 is not medically necessary.
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. The Plan covers a crown for tooth # 30 when the services are medically necessary and reasonable. 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 crown for tooth # 30. Our reviewer says that the requested crown for tooth # 30 is not medically necessary. Our physician reviewer found the provided documentation indicates that tooth # 30 has a defective restoration. The reviewer also found that there does not appear to be significant coronal breakdown which would require a crown restoration. Therefore, the reviewer found that the requested crown for tooth # 30 is not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a crown for tooth # 30 have not been met. Specifically, the file shows that there is not significant breakdown to warrant a crown for tooth # 30. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 30.
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 enrollee is being discharged from the hospital but needs ongoing acute care in an LTACH. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee has not required a prolonged acute inpatient admission so far and there is no documentation that the enrollee will benefit from and improve with LTACH management. The enrollee's medical needs are being met in the current acute setting; the LTACH would add no additional services. With additional time in the current setting, clinical stability can be ensured such that the appropriate lower level of care can be determined.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving and should only require short-term additional acute care services that can be safely received at the current facility. The enrollee does not require services at the LTACH that are not already available and covered at the current facility. Transfer to LTACH will be considered not medically necessary as there is no clear clinical advantage. Transfer to a lower level of care may be considered when treatment has completed and the enrollee is more appropriate for transfer.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (procedure code 76705) provided to the enrollee on August 23, 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 the 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 76705 is a column II code to column I code 93976. 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 (procedure code 76705) provided to the enrollee on August 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete denture - maxillary (D5110) and complete
denture - mandibular (D5120) provided August 26, 2021.
You asked the Plan to pay for the complete upper and lower dentures. You say that your previous dentures
were poorly made, and new ones were necessary. The Plan denied your request. The Plan says you have
exceeded the frequency limit for this service.
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. The Plan covers the complete
upper and lower dentures once every five plan years.
We looked at the file and Medicare rules. The Plan provided documentation showing that complete upper and
lower dentures were previously covered on June 5, 2019.
Based on this information, we decided that the Plan's frequency limit for coverage of the complete upper and lower dentures has been exceeded. Therefore, we decided that the Plan does not have to pay for the complete denture - maxillary (D5110) and complete denture - mandibular (D5120) provided August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion ophthalmology consultation to be
rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve this service. 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 service.
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 service at issue in this appeal.
We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the
Plan does not have to pre-approve a second opinion ophthalmology consultation to be rendered by the out-ofnetwork
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen rental for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there was no current documentation of a recent qualifying blood gas study.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. To qualify for home oxygen, the patient must meet one of the following blood gas levels: 1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep; 3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise; 4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia. For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage. 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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found supplemental oxygen is considered not medically necessary. The enrollee has asthma and severe obstructive sleep apnea. He uses bilateral positive airway pressure (BiPAP) with excellent compliance, and has been on supplemental oxygen, based on an SpO2 of 86% breathing room air at rest, prior to discharge from the hospital on 3/6/2020. The most recent clinical note, and the only one provided in the record, is from 6/14/2021; during that visit the SpO2 at rest was 96%. This was presumably on room air, although this is not specified. It therefore appears that the enrollee's condition has improved to the point where he no longer needs oxygen at rest. There is no documentation of hypoxemia during activity. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve an oxygen rental for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedures to improve respiratory function (G0238) provided from July 2, 2021, to July 30, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the therapeutic procedures. You say that there is sufficient evidence of medical necessity to authorize the services in question. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that these 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 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 therapeutic procedures to improve respiratory function (G0238) provided from July 2, 2021, to July 30, 2021 by an out-of-network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care at diagnosis related group (DRG) 356 from August 26, 2020, to September 2, 2020.

You asked the Plan to pay for inpatient care. You say that DRG 356 is accurate. The Plan denied your request. The Plan says the denial of payment for this inpatient DRG is correct, because secondary diagnosis code G93.41 is not supported, and the record supports DRG 357 instead.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with G93.41 septic encephalopathy. 

We asked our 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 inpatient care. Our reviewer says that this inpatient stay does not meet criteria for payment at the requested DRG of 356. Our physician reviewer found during this hospital admission there is insufficient documentation to confirm diagnosis code G93.41 septic encephalopathy as a secondary diagnosis. Septic encephalopathy is documented in the discharge summary, however, does not include clear and consistent documentation of care and management of this diagnosis throughout the admission. Per documentation, patient has abnormal calcium levels, and altered mental status, documentation does not confirm these as the cause of Septic encephalopathy. In this case a query should be made before reporting this diagnosis. 

We looked at this review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital care at diagnosis related group (DRG) 356 from August 26, 2020, to September 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a segmental pneumatic compression device (E0652, E0667) for the enrollee.  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 has been no trial of a standard compression device.  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 that in this case, the record does not indicate that the enrollee has lymphedema extending onto the chest, trunk and/or abdomen. 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 a segmental pneumatic compression device (E0652, E0667) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat lumbar/sacral facet joint block for the enrollee.
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your request. The Plan says since the pain relief from the first procedure was much less than 80%, coverage is denied.
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 block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's pain is associated with radiculopathy. The facet joint is not the main source of pain. The review has determined that the enrollee does not meet the coverage criteria detailed in the LCD. 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 block have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat lumbar/sacral facet joint block for the enrollee.