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

We decided that the Plan does not have to pre-approve Qutenza for the enrollee.

You asked the Plan to pre-approve Qutenza. You say that this is medically necessary for patient's long term health treatment of neuropathy. The Plan denied your request. The Plan says that this drug is not being prescribed for a medically-accepted indication.

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 Qutenza. Our reviewer says that Qutenza is not medically reasonable and necessary for the enrollee in this case. The enrollee has a history of hereditary and idiopathic neuropathy and unspecified peripheral neuropathy. Qutenza is not FDA-approved for the enrollee's diagnosis, nor does it have off-label use for the enrollee's condition. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Qutenza. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Qutenza have not been met. Therefore, we decided that the Plan does not have to pre-approve Qutenza for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services.
You asked the Plan to pre-approve chiropractic services. You say that you have lower back pain and have had hip surgery in the past. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is no clinical documentation of subluxation of any part of the spine.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 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 chiropractic services Our reviewer says that you do not meet the criteria for chiropractic care. Our physician reviewer found the record shows that you have hip and calf pain. The records provided do not indicate the presence of subluxation by either examination or X-Ray. Therefore, Medicare coverage criteria are not met, and the requested service cannot be recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of chiropractic services have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic services.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chemotherapy services (96413) provided May 6, 2021.
You asked the Plan to pay for the chemotherapy services. You say that the services were medically necessary.
The Plan denied your request. The Plan says the claim cannot be paid 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.
We find that CPT code 96413 is not supported in the medical record. Specifically, there is a more appropriate
code to describe the service performed. Based on this information, we decided that Medicare rules for coverage
of the chemotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for
chemotherapy services (96413) provided May 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided from August 31, 2020, through September 16, 2020.
You asked the Plan to pay for physical therapy. The Plan denied your request. The Plan says prior authorization was not obtained. Services are 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physical therapy. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physical therapy provided from August 31, 2020, through September 16, 2020.
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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.
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: 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do 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. 

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 pay for the periodontal maintenance (D4910) provided on May 24, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the periodontal maintenance. You say that you feel the Plan should pay for this service because they initially provided you with an incorrect denial reason. The Plan denied your request. The Plan says this service was rendered by a non-contracted dentist. The Plan also says that services must be provided by contracted providers in order to be covered.
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 items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on May 24, 2021 by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office services provided from March 8, 2021, to June 1, 2021, by a provider who has opted out of Medicare.
You asked the Plan to pay for the office services. You say that you believe that these services should be covered based on your medical condition. The Plan denied your request. The Plan says payment is not made for providers who have opted out of Medicare.
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. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office services provided from March 8, 2021, to June 1, 2021, by a provider who has opted out of Medicare
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep sedation/general anesthesia (D9222, D9223 x2).
You asked the Plan to pre-approve deep sedation/general anesthesia. You say that the service is necessary. The
Plan denied your request. The Plan says the services at issue are not covered benefits.
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 items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve deep
sedation/general anesthesia (D9222, D9223 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an infusion pump (E0779) provided August 3, 2020.
You asked the Plan to pay for the infusion pump. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid physician order. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for an infusion pump (E0779) provided August 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the
cranial cavity you had on October 5, 2020.

You asked the Plan to waive the copayment for the CT scan. You say that you have never received a bill in the
past for these types of tests. You said that this cost is a financial hardship for you. The Plan denied your
request. The Plan says you were charged this copayment 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 a $50
copayment for radiological diagnostic services (including CT scans).

You have been asked to pay a $50 copayment for the CT scan. The CT scan falls within the radiological
diagnostic services 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 the computed
tomography (CT) scan of the cranial cavity you had on October 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on February 22, 2021 by a Medicare opt out provider.

You asked the Plan to pay for the prophylaxis. You say that services rendered by this provider were covered last year. You also say that you feel you should have been notified that the Plan was no longer covering procedures rendered by this provider. The Plan denied your request. The Plan says you received this service from a provider who chose not to receive Medicare funds. The Plan also says that they reached out to the treating provider's office who stated that they make their patients verbally aware that they do not accept Medicare.

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 items or services are not covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the
Plan does not have to pay for the prophylaxis (D1110) provided on February 22, 2021 by a Medicare opt out provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional payment for a left ear hearing aid.

You asked the Plan to pre-approve the additional payment. You say that this is medically necessary. The Plan denied your request. The Plan says the remaining balance of $550 cannot be covered, as the benefit is exhausted.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The health plan contract says that the plan covers up $1,050 per hearing aid per ear ($2,100 maximum benefit) every three years. 

The cost of the requested item is $1600. There is a maximum benefit of $1,050 per ear. The remaining $550 is your responsibility. Based on this information, we decided that the Plan's rules for coverage of the additional payment have not been met. Therefore, we decided that the Plan does not have to pre-approve additional payment for a left ear hearing aid.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on April 4, 2021.
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's
attending or primary care physician.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of psychotherapy services have not been met. Specifically, the provided records do not document an
attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we
decided that the Plan does not have to pay for psychotherapy services (90832) provided on April 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on May 21, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you believe the ambulance services should be classed as medically necessary. The Plan denied your request. The Plan says since there was no transport, ambulance charges are not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on May 21, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on May 21, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services provided on November 25, 2020.

You asked the Plan to pay for the services provided. You say that the enrollee was seen twice on the same date of service. The Plan denied your request. The Plan says the claim for service denied correctly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the CPT Code Manual definition of code 99283 is Emergency department visit for the evaluation and management of a patient, usually, the presenting problem(s) are of moderate severity. 

We find that CPT code 99283 was billed with code 99284. We looked at the file and the rules. CPT code 99283 may be eligible for separate payment when billed with this code pair. However, the claim does not show that the code was billed with an appropriate modifier. Based on this information, we decided that the Medicare rules for coverage have not been met.

Medicare rules say that for bundled procedures, payment for covered services is always bundled into payment for other services not specified. In this case, the CPT Code Manual definition of code 99053 is Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service. 

We find that CPT code 99053 is a bundled code. Payment for this service is subsumed by the payment for the services to which they are incident. This code is not separately payable. Therefore, we decided that the Plan does not have to further pay for the emergency room services provided on November 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder orthosis (L3960), provided on October 12, 2020.
You asked the Plan to pay for the shoulder orthosis. You say that the item is medically necessary. The Plan denied your request. The Plan says documentation submitted did not include medical records from the ordering physician to indicate the provider discussed the need for the billed supply code. In addition, the physician order was submitted to the supplier on September 28, 2020 and signed on October 7, 2020; however, claims history shows the member's last visit to the provider was August 3, 2020.
Outreach was made to the provider to validate the physician order, but attempts were unsuccessful; therefore, the billed supply code could not be verified.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order or relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the shoulder orthosis (L3960), provided on October 12, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the insertion of ventricular assist device (33979) provided on March 25, 2021.
You asked the Plan to pay for the insertion of ventricular assist device. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says that the procedure billed was reported without an approved diagnosis.
The Plan follows Medicare rules. Medicare rules say that the medical necessity of the ventricular assist device is subject to the criteria listed 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 pay for the insertion of ventricular assist device. Our reviewer says that the requested procedure was medically reasonable and necessary. Our physician reviewer found the enrollee is 54-year-old woman with history of cardiomyopathy were severely reduced ejection fraction. She has had prior surgery for both mitral and tricuspid valve disease with valve failure. She was admitted in March 2021 for recurrent congestive heart failure and referred for mitral and tricuspid valve replacement as part of a third thoracotomy surgery for her.
A Heartmate LVAD was placed during the operation to support her circulatory status in the postoperative period given her severe underlying cardiomyopathy. In this case, the patient had severe known heart failure secondary to cardiomyopathy with reduced ejection fraction and was facing a third thoracotomy operation for bi-valvular disease. She was at high risk for intra-operative and post-operative complications due to cardiac failure, especially in the immediate post-operative period, given here markedly reduced ejection fraction and prior congestive heart failure. The Heartmate LVAD device used meets appropriate diagnostic and regulatory criteria of the applicable NCD for use in this clinical situation. 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 insertion of ventricular assist device have been met. Therefore, we decided that the Plan has to pay for the insertion of ventricular assist device (33979) provided on March 25, 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.