Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunotherapy injection provided on April 8, 2021 by a non-participating provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating provider without prior authorization.
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 the immunotherapy injection provided on
April 8, 2021 by a non-participating provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo and Yervoy.
You asked the Plan to pre-approve the Opdivo and Yervoy. You say that you would like reconsideration because the requested drugs are medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of Opdivo combined with Yervoy in the setting of known disease progression on Keytruda have not been demonstrated in the peer-reviewed literature.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Opdivo and Yervoy. Our reviewer says that the Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Our physician reviewer found 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 Opdivo and Yervoy have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo and Yervoy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alignable system (L5910) for a leg prosthesis 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 while the quote from the vendor includes L5910, the physician office visit notes do not corroborate the need to replace this item.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the physician documentation does not support the need for a new alignable system. There is no evidence of damage or that the enrollee is unable to use the already approved alignable system that he has.
The L5910 does not meet medically necessary criteria as Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. 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 alignable system (L5910) for a leg prosthesis for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (95886, 95908) provided on April 26, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are not supported.
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 95886 is "Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure)". The CPT Code Manual definition of code 95908 is "Nerve conduction studies; 3-4 studies".
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 services. Our reviewer says that the use of codes 95886 and 95908 is not supported by the records provided. Our reviewer found that the technical report does not include documentation of nerve conduction studies. Nerve conduction studies should not be reported for "pedicle screw stimulation. Nerve conduction studies measure amplitude, latency, and conduction velocity. This was not documented in the technical report, and therefore cannot be verified. CPT 95886 is not supported by the technical report, as nerve conduction testing was not verified as performed. Per CPT 95886 description, this procedure includes nerve conduction studies. All criteria described in any CPT code must be performed in order to report, unless an appropriate modifier is appended. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (95886, 95908) provided on April 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the recommendation is to discharge home with home health. 
 
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 the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found you have 
stabilized medically without any acute exacerbations of chronic medical problems, and are ready for discharge 
from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. You are 
medically stable and can receive further rehabilitation services at a lower level of care. Although further 
rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled 
services can be provided at a lower level of care than a skilled nursing facility. You do not have any parenteral 
medication, complex wound care or nutrition given via a feeding tube. Your physical function is at or near the 
baseline. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code(s): 22869 and 22870), for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this treatment is considered safe and effective, as 
supported by its clinical benefits to patients, continued medical professional adoption, and strong clinical 
evidence with numerous peer-reviewed studies. The Plan denied your request. The Plan says medical studies 
have not proven that the service(s) or procedure(s) is helpful for treatment of the enrollee's health problem. 
 
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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertilfex spacer 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 surgery have not been met.  
 
 
Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement 
surgery (CPT code(s): 22869 and 22870), for the enrollee
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gemcitabine Hydrochloride (J9201).
You asked the Plan to pre-approve Gemcitabine Hydrochloride. You say that you have tried other drugs which did not provide the relevant results and your condition did not improve. You also say that the treatment with Gezmar in conjunction with Keytruda will benefit you. The Plan denied your request. The Plan says this drug is not medically necessary for you.
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 Gemcitabine Hydrochloride. Our reviewer says that the elements of the coverage criteria are not satisfied. Our physician reviewer found the record indicates that you have a diagnosis of pancreatic cancer. The Food and Drug Administration has not stated that the requested drug is indicated for your condition. Our reviewer found that the Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in your clinical situation. Our physician reviewer also found that no literature from Medicare approved cancer journals were submitted for review.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gemcitabine Hydrochloride have not been met. Therefore, we decided that the Plan does not have to pre-approve Gemcitabine Hydrochloride (J9201).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six (6) additional skilled nursing visits (CPT code G0299 X 6), for the enrollee.
You asked the Plan to pre-approve the skilled nursing visits. You say that the services are necessary. The Plan denied your request. The Plan says the enrollee's previously approved visits should have allowed the enrollee's nurse to review their medical conditions, medication management, pain management, diet, and household safety with the enrollee. The Plan states the enrollee's records do not support the need for a skilled nurse to make more visits.
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 the skilled nursing visits. Our physician reviewer found the documentation does not support that the enrollee requires additional skilled nursing services to provide treatment that is medically necessary. The enrollee does not require additional skilled nursing 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 enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. 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 the skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve six (6) additional skilled nursing visits (CPT code G0299 X 6), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services coded as 52005-59 and 52318 provided 
on January 21, 2020. 
 
You asked the Plan to pay for the medical services. You say that you would like these claims reprocessed and 
approved for payment. The Plan denied your request. The Plan says the codes as billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that the provider, supplier, or 
beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine 
whether payment is due and the amount of payment. 
 
We find that CPT codes 52005-59 and 52318 are not supported in the medical record. Specifically, there were 
no medical records provided in this case. Without the medical records, we cannot determine if the requested 
services were coded correctly. Based on this information, we decided that Medicare rules for coverage of the 
medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical 
services coded as 52005-59 and 52318 provided on January 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for vertigo and hypertensive urgency. Medical problems are stable.
There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.
You asked the Plan to pre-approve a stair glide. You say that following knee replacement surgery this device will be necessary. The Plan denied your request. The Plan says the requested device is not covered by Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (74018) provided on May 24, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
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 74018 is a column II code to column I code 74250. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (74018) 
provided on May 24, 2021.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
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 you continue to receive acute care services, and these have not been denied. The medical record does not indicate that you require services that you are not currently receiving but that would be available at the LTACH 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. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on April 19, 2021 by 
a Medicare opt out provider. 
 
You asked the Plan to pay for the panoramic x-ray. You say that at the time this service was rendered, you were 
not aware of the network system, nor were you advised that the treating provider was not in-network. You also 
say that the provider would not accept your insurance card, so you paid the cost. The Plan denied your request. 
The Plan says this service was rendered by a Medicare opt out provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received by a provider who has opted out of Medicare. The record shows that the Plan 
has verified that you were informed by the provider that insurance would not be accepted. Therefore, we 
decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on April 19, 2021 by a 
Medicare opt out provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the back brace you received on  
December 16, 2020. 
 
You asked the Plan to waive the coinsurance for the back brace. You say that this brace is much cheaper online 
and you offered to return it. The Plan denied your request. The Plan says you were charged this coinsurance 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for prosthetic devices (including braces).  
 
You have been asked to pay 20% coinsurance for the back brace. The back brace falls within the prosthetic 
devices benefit category. This cost sharing applies even if you can purchase the item cheaper online. 
 
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 the back brace you received on December 16, 2020.