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

 We decided that the Plan does not have to pay for the adjacent tissue transfer (14040) provided on August 28, 2020.  You asked the Plan to pay for the adjacent tissue transfer (14040). You say that the submitted documentation supports CPT code 14040. You say that the documentation should be reviewed and reprocessed for payment. The Plan denied your request. The Plan says CPT code 14040 is not supported in the documentation, therefore is not payable.  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 14040 is adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less.  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 adjacent tissue transfer (14040). Our reviewer says that this does not meet the criteria for billing or reimbursement purposes. Our reviewer found that the medical records provided do not include sufficient documentation of the exact dimensions of the primary and secondary defects and additional incisions that were performed to create the tissue flap. Therefore, an adjacent tissue transfer or rearrangement cannot be verified as the procedure performed.  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 adjacent tissue transfer (14040) have not been met. Therefore, we decided that the Plan does not have to pay for the adjacent tissue transfer (14040) provided on August 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycodone 20mg tablets for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this self-administered drug does not fall under Part B coverage.

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 Oxycodone 20mg tablets for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Eligard.

You asked the Plan to pre-approve Eligard. You say that this drug is needed by the enrollee. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug will be dispensed by a pharmacy so is not covered by Medicare Part B.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve use of Eligard.

Benefits for Eligard 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 pre-approve an out-of-network referral for physical therapy.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says medically necessary care is available in-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 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 an out-of-network referral for physical therapy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Levothyroxine.

You asked the Plan to pre-approve Levothyroxine. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B benefit.

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 Levothyroxine.

Benefits for Levothyroxine 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 Botox (J0585).

You asked the Plan to pre-approve Botox. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the medical benefit per the way it is being dispensed.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Botox (J0585).

Benefits for Botox 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 treatment with Euflexxa.

You asked the Plan to pre-approve Euflexxa. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met for the requested treatment.

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Specifically, the case record does not contain medical documentation to support the medical necessity of the services at issue. Therefore, we decided that the Plan does not have to pre-approve treatment with Euflexxa.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xarelto tablets 20mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says this self-administered drug does not fall under Part B coverage.
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 20mg for the
enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Omega-3 acid capsule.

You asked the Plan to pre-approve Omega-3 acid. 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 Omega-3 acid capsule.

Benefits for Omega-3 acid 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 10mg Prednisone Tablets.

You asked the Plan to pre-approve the Prednisone Tablets. You say that you would like reconsideration because the requested drug is medically necessary. The Plan denied your request. The Plan 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 10mg Prednisone Tablets.

Benefits for the Prednisone 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Coaguchek XS.

You asked the Plan to pre-approve a tier exception. The Plan denied your request. The Plan says tier exceptions are not available for Part B coverage.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 

We looked at the file and the rules. Medicare does not grant tier or cost exemption to Part b drugs or durable medical equipment and supplies. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Coaguchek XS.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis 5 mg tablet.

You asked the Plan to pre-approve Eliquis. You say that this medication is needed for the enrollee's diagnosis. You also say that it is needed to prevent a recurrence of a pulmonary embolus. 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 Eliquis 5 mg tablet.

Benefits for Eliquis 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 pre-approve an out-of-network electrophysiology referral.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are network providers available.

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 an out-of-network electrophysiology referral.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to waive the copayment for chiropractic services (98940) received September 29, 2021.  You asked the Plan to waive the copayment for chiropractic services. You say that you met your out-of-pocket maximum and should not have a copayment. The Plan denied your request. The Plan says that you did not meet your maximum out-of-pocket before the services at issue.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a maximum out-of-pocket of $4,250 for in-network services.   The Plan says you must pay a $20 copayment for chiropractic services. Based on the Plan contract, however, you cannot be asked to pay more than the maximum out-of-pocket of $4,250 for in-network services. The record does not show that you did not reach the maximum out-of-pocket of $4,250 for the 2021 Plan year, prior to the services at issue. The documentation submitted by the Plan appears to indicate that you did reach the maximum out-of-pocket amount for 2021, prior to receiving the services at issue. Therefore, we decided that the Plan has to waive the copayment for chiropractic services (98940) received September 29, 2021.   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: Favorable

We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the Spine (72141).  You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.  The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the requested MRI is medically necessary. Our physician reviewer found the medical records indicate that the patient had a recent stroke and has evidence of a continued myelopathy problem with the spinal cord and nerve roots with leg weakness and coordination problems. MRI of the cervical and lumbar spines is needed to rule out cord compression as a cause for the weakness.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have been met. Therefore, we decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the Spine (72141).   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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis.  You asked the Plan to pre-approve Eliquis. 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 Eliquis.   Benefits for Eliquis 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 Orthovisc.  You asked the Plan to pre-approve Orthovisc. You say that this is medically necessary for your condition. The Plan denied your request. The Plan says the criteria for coverage is not met as per the enrollee's condition.  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.   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 Orthovisc. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found that the review indicates that you are a 65-year-old female with bilateral knee pain. You have X-ray evidence of right knee osteoarthritis, have received prior viscosupplementation with Orthovisc, and will eventually require a right total knee replacement. The left knee has no x-ray evidence of osteoarthritis.  The provider has recommended viscosupplementation therapy with Orthovisc for the left knee.  Intra-articular injections with hyaluronic acid (Orthovisc) are recommended as a possible option for severe osteoarthritis for patients who have not responded adequately to recommended conservative treatments (exercise, NSAIDs, and/or Acetaminophen) to potentially delay total knee replacement.  However, in recent quality studies, the magnitude of improvement appears modest at best. While osteoarthritis of the knee is a recommended indication, there is insufficient evidence for other conditions, including patellofemoral arthritis, chondromalacia patellae, osteochondritis dissecans, or patellofemoral syndrome (patellar knee pain).  Hyaluronic acids are naturally occurring substances in the body's connective tissues that cushion and lubricate the joints.  Intra-articular injection of hyaluronic acid can decrease symptoms of osteoarthritis of the knee; there are significant improvements in pain and functional outcomes with few adverse events. Therefore, the review indicates that the requested use of Orthovisc is not FDA-approved for the enrollee's diagnosis.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on April 29, 2021.  You asked the Plan to waive the copayment for the ER visit. You say that you were there for 2.5 hours and did not see a doctor. 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 $90 copayment for each emergency room visit.   The record shows you were seen and evaluated by the ER triage staff. Therefore, you have been asked to pay $84.59, which is less than the $90 copayment for the ER visit. The ER visit falls within the Emergency Care 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 an emergency room (ER) visit provided on April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve intermittent limb compression devices (E0651, E0667).  You asked the Plan to pre-approve intermittent limb compression devices. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested items have not been met.  The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.  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 intermittent limb compression devices. Our reviewer says that the requested items are not medically reasonable and necessary in this case. Our physician reviewer found that there is no evidence in the records of an ulcer, lymphedema, or other special circumstance to justify this request.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intermittent limb compression devices have not been met. Therefore, we decided that the Plan does not have to pre-approve intermittent limb compression devices (E0651, E0667).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.  You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental and 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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the procedure is experimental. More research is needed to show safety and efficacy.  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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.