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

We decided that the Plan does not have to pre-approve a neurology office consult and follow up visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a neurology office consult and follow up visit. You say that you need these services to see if this provider will accept your case. The Plan denied your request. The Plan says the requested services can be provided by a network provider.

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 a neurology office consult and follow up visit to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  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 enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve out of network dental visits.  You asked the Plan to pre-approve out of network dental visits. You say that you would like to see an out of network dentist. The Plan denied your request. The Plan says there are in network dentists available.  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.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested out of network dental visits are not among those covered under this benefit. Additionally, the record shows there are in network dentists available as early as January 2022. Therefore, we decided that the Plan does not have to pre-approve out of network dental visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve gradient compression stockings and non-elastic binder for an extremity.  You asked the Plan to pre-approve gradient compression stockings and non-elastic binder for an extremity. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. Medicare rules say that certain wound care items are non-covered under the surgical dressing benefit.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of gradient compression stockings and non-elastic binder for an extremity have not been met. Therefore, we decided that the Plan does not have to pre-approve gradient compression stockings and non-elastic binder for an extremity.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve massage therapy.  You asked the Plan to pre-approve massage therapy. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve romosozumab-aqqg, 1MG injection (CPT code J3111 x12), for the enrollee.  You asked the Plan to pre-approve the injection. You say that the enrollee is being treated for osteoporosis and they have had multiple fragility fractures in the past five (5) years, requiring multiple hospital stays and surgeries. You state the enrollee is a candidate for anabolic medication romosuzumab, regardless of dexa scores. You state that you are asking approval of this medication as the enrollee is very high risk for another fracture, resulting in hospitalization, surgery, long rehabilitation stay, or death. The Plan denied your request. The Plan says they do not have a record from the enrollee's prescriber that shows they have tried one of the preferred drugs Prolia or Reclast (zoledronic acid), and it has not worked, or that the enrollee has medical reasons that prevent the enrollee from using one of them.  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 the injection. Our physician reviewer found the Plan requires a trial of drug romosozumab-aqqg, 1MG injection before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely 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 the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve romosozumab-aqqg, 1MG injection (CPT code J3111 x12), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the removal of intact breast implant (19328) provided on May 5, 2021.  You asked the Plan to pay for the removal of intact breast implant. You say that you would like this claim reprocessed. The Plan denied your request. The Plan says no separate payment is made for this code 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, the CPT Code Manual definition of code 19328 is removal of intact breast implant.  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 removal of intact breast implant. Our reviewer says that the documentation does not support payment for the claim as billed. Our reviewer found operative report documents a "Bilateral total en bloc capsulectomy and implant removal" was performed. Capsulectomy procedure is removal of breast implant and entire capsule of scar tissue. Therefore, the removal of an intact implant would be included with the capsulectomy (19371) and should not be reported separately.  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 removal of intact breast implant have not been met. Therefore, we decided that the Plan does not have to pay for the removal of intact breast implant (19328) provided on May 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for needle electromyography (95885), neuromuscular junction testing (95937) and nerve conduction studies (95910) provided on September 3, 2021.  You asked the Plan to pay for the needle electromyography, neuromuscular junction testing and nerve conduction studies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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.  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 needle electromyography, neuromuscular junction testing and nerve conduction studies. Our reviewer says that CPT code 95885 does not meet criteria for billing or reimbursement consideration. Technical report does not document nerve conduction studies. Per CPT description needle electromyography is done with nerve conduction studies, as this procedure cannot be verified, this procedure would not be covered. CPT code 95937 does not meet criteria for billing or reimbursement consideration.  Per the technical report "A Train of Four (Neuromuscular Junction Blockade) test was used to monitor muscle relaxation throughout the case".  This is the incorrect code to report for Train of Four.  There is no separate procedure code to report for Train of Four.  Train of four is bundled with the intraoperative neuromonitoring service. Our reviewer found CPT code 95910 does not meet criteria for billing or reimbursement consideration. Nerve conduction studies are not documented in the procedure report, as nerve conduction studies are not Pedicle screw stimulation.  Nerve conduction measure amplitude and latency/velocity.  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 needle electromyography, neuromuscular junction testing and nerve conduction studies have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95885), neuromuscular junction testing (95937) and nerve conduction studies (95910) provided on September 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that you are a fall risk as you are not up and moving around on your own. You say that you are not able to care for yourself. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met.  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 enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical management of a femur fracture after a fall. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SNF care.  You asked the Plan to pre-approve SNF care. You say that you went to the hospital because you could not get out of bed due to not having strength and feeling weak causing incontinence in bed. You state you know that you need to go but cannot get out of bed to go to the bathroom. The Plan denied your request. The Plan says the stay is not medically necessary based on SNF criteria. The Plan states the care can be provided at a lower level of care.  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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not shown to require the services to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at a lower level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional healthy meals.  You asked the Plan to pre-approve additional healthy meals. The Plan denied your request. The Plan says you have exhausted your healthy meals supplemental benefit and you are not eligible for any additional meals.  The Plan contract offers a supplemental Healthy Meals-Chronic Condition benefit. The benefit covers $0.00 copay for covered healthy meals that address chronic conditions. You may qualify to receive 2 home-delivered meals per day for up to 90 consecutive days.  We looked at the file and the Plan's rules. The file shows that you received 182 delivered healthy meals between February 1, 2021, and April 26, 2021 and then approved for 180 additional meals June 25, 2021. You received 182 additional meals between June 30, 2021, and November 8, 2021. Based on these findings, you have exhausted your healthy meals supplemental benefit. Therefore, we decided that the Plan does not have to pre-approve additional healthy meals.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the CT scan, abdomen and pelvis; without contrast material (CPT code 74176) provided to the enrollee on August 30, 2021.  You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 74174 and 74176 This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. Therefore, we decided that the Plan does not have to pay for the CT scan, abdomen and pelvis; without contrast material (CPT code 74176) provided to the enrollee on August 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a tie down kit (K0108).  You asked the Plan to pre-approve a tie down kit. You say that the item is medically necessary. The Plan denied your request. The Plan says this item is for use in transportation and not for home use.  The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.   The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a tie down kit (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the headgear (A0745).  You asked the Plan to pre-approve the headgear. You say that the item is medically necessary. The Plan denied your request. The Plan says the request is for a quantity of supplies greater than the usual maximum amounts and is therefore not reasonable and necessary.  The Plan must follow Medicare rules. Medicare rules say that continuous positive airway pressure (CPAP) headgear is approved at a rate of one every six months  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the headgear have not been met. Therefore, we decided that the Plan does not have to pre-approve the headgear (A0745).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery.  You asked the Plan to pre-approve Vertiflex Superion device placement surgery. You say that 3 doctors feel that the requested surgery would be best to help with the enrollee's back problems. You say that if the procedure isn't performed soon, it could become worse. The Plan denied your request. The Plan says there are not enough studies to show that the use of the Vertiflex Superion device is better than regular spine surgery for the enrollee's problem. The Plan says that there are not enough studies to show that the use of the Vertiflex Superion device will help in the enrollee's care.  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 Vertiflex Superion device placement surgery. Our reviewer says that Vertiflex Superion device placement surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back pain and spinal stenosis. The record indicates that imaging has demonstrated no significant central or foraminal stenosis.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex Superion device placement surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Lutathera.  You asked the Plan to pre-approve Lutathera. You say that this is medically reasonable for the enrollee's condition. The Plan denied your request. The Plan says there is no support for using this drug for the enrollee's medical condition.  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 Lutathera. Our reviewer says that the requested drug is not medically reasonable and necessary for the enrollee's condition. In this case, Lutathera is not FDA-approved for prostate cancer. It is FDA-approved for the treatment of somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumors (GEP-NETs) in adults, including foregut, midgut, and hindgut neuroendocrine tumors. In addition, the use of Lutathera is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. Our physician reviewer found the enrollee has been diagnosed with metastatic cancer. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Lutathera have not been met. Therefore, we decided that the Plan does not have to pre-approve Lutathera.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eylea.  You asked the Plan to pre-approve Eylea. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been satisfied.    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 Eylea. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of bevacizumab (Avastin) before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s) would likely be less effective and/or likely 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 Eylea have not been met. Therefore, we decided that the Plan does not have to pre-approve Eylea.