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

We decided that the Plan does not have to pay for the pharmacogenomics (PGx) panel provided on May 4, 2021.

You asked the Plan to pay for the PGx panel. You say that this was ordered by the treating provider who believed it was medically necessary. The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that PGx is covered only when the record clearly demonstrates the intent to use the information from the test to define safe use of specific drugs in a patient. 

We looked at the file and Medicare rules. The documentation is not sufficient to support that this expanded panel is reasonable and necessary as there is no specific discussion in the records of the need to prescribe drugs that are affected by all the genes tested. Based on this information, we decided that Medicare rules for coverage of the PGx panel have not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenomics (PGx) panel provided on May 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fluid circulating cold pad with a pump (E0218).

You asked the Plan to pre-approve a fluid circulating cold pad with a pump. You say that you need this because of your upcoming surgery. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) will be denied as not reasonable and necessary. 

We looked at the file and Medicare rules. The item at issue is not considered medically necessary. Based on this information, we decided that Medicare rules for coverage of a fluid circulating cold pad with a pump have not been met. Therefore, we decided that the Plan does not have to pre-approve a fluid circulating cold pad with a pump (E0218).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (77003) provided on May 17, 2021.

You asked the Plan to pay for code 77003. You say that you would like the Plan to reconsider their denial of payment. 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. In this case, we have confirmed that code 77003 is an add-on code and has not been billed with an appropriate primary procedure code. 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 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (77003) provided on May 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee arthroscopy procedures (29877, 29881) to be provided by an out-of-network provider.
You asked the Plan to pre-approve knee arthroscopy procedures. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for out-of-network care have not been met.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve knee arthroscopy procedures (29877, 29881) to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the elastic knee sleeve (A4467) provided November 3, 2021.
You asked the Plan to pay for the elastic knee sleeve. You say that after your knee surgery you needed extra
support and asked your doctor if he had any knee sleeves. The Plan denied your request. The Plan says this
item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pay for the elastic knee sleeve (A4467) provided November 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) for the sacroiliac joint (64625).
You asked the Plan to pre-approve RFA treatment. You say that the enrollee has experienced limited benefit with sacroiliac joint injections and had a good response to a lateral branch block in preparation for this treatment. The Plan denied your request. The Plan says research has not proven this service to be helpful, and therefore this treatment is 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 RFA treatment. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested procedure is considered experimental/investigational due to wide variation in efficacy reported in the literature. Therefore, the request is not deemed medically reasonable or 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 RFA treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) for the sacroiliac joint (64625).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder arthroscopy with debridement (29823) provided
on August 10, 2021.
You asked the Plan to pay for the shoulder arthroscopy with debridement (29823). You say that the
documentation supports three or more discrete structures were debrided. You say that this code does not bundle
with any other code billed and the coding is correct. The Plan denied your request. The Plan says CPT code
29823 is not supported by the medical records.
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 29823 is arthroscopy, shoulder, surgical; debridement,
extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid
articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator
cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]).
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the
Plan was correct in denying the request to pay for the shoulder arthroscopy (29823). Our reviewer says that the
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that
the operative report does not confirm extensive debridement was performed therefore, the procedure cannot be
verified.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the shoulder arthroscopy (29823) have not been met. Therefore, we decided that
the Plan does not have to pay for the shoulder arthroscopy with debridement (29823) provided on August 10,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office or outpatient visit (99215) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the office or outpatient visit. You say that it is medically necessary for these services to be rendered by an OON provider. The Plan denied your request. The Plan says there are multiple in-network providers available to meet your care needs.

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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office or outpatient visit (99215) to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.

You asked the Plan to pre-approve continued SNF care. You say that you are appealing coverage for continued care. The Plan denied your request. The Plan says skilled nursing services are no longer needed.

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 continued SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you do not require the skilled services of a nurse and daily skilled therapy is not required. 

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 SNF 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiofrequency ablation of genicular nerve (64624).
You asked the Plan to pre-approve a radiofrequency ablation of genicular nerve. You say that the requested
services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for
coverage have not been met because the requested treatment is experimental/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 a radiofrequency ablation of genicular
nerve. Our reviewer says that the requested services are not considered medically reasonable and necessary in
this case. Our physician reviewer found that genicular nerve blocks and genicular nerve radiofrequency
ablation are considered investigational and not medically necessary for the treatment of chronic knee pain,
including but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a
treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for
individuals who are not candidates for knee replacement surgery.
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 radiofrequency ablation of genicular nerve have not been met. Therefore, we
decided that the Plan does not have to pre-approve a radiofrequency ablation of genicular nerve (64624).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Feraheme.

You asked the Plan to pre-approve Feraheme. You say that 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 Feraheme. Our reviewer says that the requirements for coverage of Feraheme have not been met. Our physician reviewer found the Plan requires a trial of Infed (iron dextran) and Venofer (iron sucrose) before they will approve the requested drug. In this case, the patient has not tried and failed the required drugs. 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 Feraheme have not been met. Therefore, we decided that the Plan does not have to pre-approve Feraheme.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hemophilus influenza B and shingles vaccines (90472, 90648, 90750 and 90471) provided on November 1, 2021.  You asked the Plan to pay for the homephilus influenza B and shingles vaccines. You say that you would like reconsideration because these vaccines are medically necessary due to your condition. The Plan denied your request. The Plan says these vaccine are not covered under Medicare Part B.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the homephilus influenza B and shingles vaccines. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to the homephilus influenza B and shingles vaccines. Therefore, we decided that the Plan does not have to pay for the hemophilus influenza B and shingles vaccines (90472, 90648, 90750 and 90471) provided on November 1, 2021.   Benefits for the homephilus influenza B and shingles vaccines 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve True Metrix Glucose test strips.
You asked the Plan to pre-approve True Metrix Glucose test strips. You say that these are medically necessary.
The Plan denied your request. The Plan says that records received do not state why you cannot use the
preferred strips that are covered by the Plan.
The Plan must follow Medicare rules. Medicare rules say that the physician or treating practitioner must
document in the beneficiary's medical record the reason why the specific brand or mode of delivery is
necessary to avoid an adverse medical outcome.
We looked at the file and Medicare rules. The file does not include any documentation from your physician
documenting why you require this specific brand of test strips. Without this, medical necessity cannot be
established. Therefore, we decided that the Plan does not have to pre-approve True Metrix Glucose test strips.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Pregabalin capsule, 100 mg.  

You asked the Plan to pre-approve Pregabalin capsule. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under 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 Pregabalin capsule, 100 mg.   

Benefits for Pregabalin capsule 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha push injection.
You asked the Plan to pre-approve Repatha push injection. You say that the requested drug is medically
necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also
says the requested drug is not covered under 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 Repatha push injection.
Benefits for Repatha push injection 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 long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that you have been in the hospital for three weeks and need to be transferred to this LTACH, which is closer to your family and friends. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee is currently unstable for transfer and is receiving medically necessary acute and/or critical care in the current hospital. The enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which an LTACH may offer a therapeutic advantage. The Plan will continue to cover medically necessary acute and critical care at the current facility until the enrollee's condition is stable for transfer to a lower level of care or until the clinical circumstances change such that an LTACH may be reconsidered.

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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace.
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot
orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xarelto tablets for the enrollee.

You asked the Plan to pre-approve Xarelto tablets. You say that Xarelto tablets are medically necessary. The Plan denied your request. The Plan says Xarelto tablets are not covered under 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 Xarelto tablets for the enrollee.

Benefits for Xarelto tablets 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) vaccine (90715 and 90471) provided on September 3, 2021.   You asked the Plan to pay for the Tdap vaccine. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this vaccine is not covered under Medicare Part B.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) vaccine (90715 and 90471) provided on September 3, 2021.    Benefits for the Tdap vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.