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

We decided that the Plan does not have to pre-approve orthopedic services to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested services.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve orthopedic services to be rendered by the out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided May 4, 2020 to May 15, 2020.

You asked the Plan to pay for inpatient hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says DRG 178 more appropriately describes the services at issue.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. 

In this case, you billed the inpatient services provided with DRG 871. 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 inpatient hospital care. Our reviewer says that the records do not support DRG 871. Our physician reviewer found records do not document hypotension or cardiovascular instability requiring vasopressor use or renal, hepatic or neurologic decompensation requiring specific interventions or intensive care unit monitoring. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided May 4, 2020 to May 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance and ultrasonic guidance for needle placement.
You asked the Plan to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance and ultrasonic guidance for needle placement. 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 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 destruction by neurolytic agent, genicular nerve branches including imaging guidance and ultrasonic guidance for needle placement. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient literature to support the use of the requested service in your specific clinical situation. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria
are not satisfied. The requested service is not 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 destruction by neurolytic agent, genicular nerve branches including imaging guidance and ultrasonic guidance for needle placement have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance and ultrasonic guidance for needle placement.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF 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 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 have made slow progress with therapy, there is no indication that transfer to a skilled nursing facility is required. You can continue to receive skilled rehabilitation services at the current inpatient rehabilitation facility or be stepped down to a lower level of care when appropriate. 

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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint radiofrequency ablation.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the guidelines only allow for two procedures per year.

The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation can be covered twice per year. 

The file shows that this same procedure was received twice in the past year on January 6, 2021 and September 22, 2021. This would not be able to be covered again until January 6, 2022. 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 facet joint radiofrequency ablation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (denosumab) injections.

You asked the Plan to pre-approve the Prolia injections. You say that this should be covered. The Plan denied your request. The Plan says the preferred drugs have not been tried as required by step therapy rules.

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 Prolia injections. Our reviewer says that the requested drug is not considered reasonable and necessary based on step therapy criteria. Our physician reviewer found the Plan requires a trial of an oral bisphosphonate as well as injectable zoledronic acid prior to approving Prolia. In this case, the record indicates that the enrollee has age related osteoporosis with high risk of fracture. The requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record provided insufficiently documents the specific clinical scenario to support the general claims that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one alternative. 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 Prolia injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (denosumab) injections.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for 30 units of Kyprolis (J9047) discarded on July 14, 2020.

You asked the Plan to pay for the 30 units of Kyprolis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that drug waste is reimbursed based on the smallest vial size available to produce the patient's dose.

The Plan must follow Medicare rules. Medicare rules say that the program provides payment for the amount of drug or biological discarded as well as the dose administered, up to the amount of the drug or biological as indicated on the vial or package label. 

We find that CPT code J9047 is supported in the record. Specifically, the documentation clearly indicates that 30 units of Kyprolis were administered and 30 units were discarded. There are no Medicare guidelines indicating that payment is only made for the smallest vial size. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. Based on this information, we decided that Medicare rules for coverage of the 30 units of Kyprolis have been met. Therefore, we decided that the Plan has to pay for 30 units of Kyprolis (J9047) discarded on July 14, 2020.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal for tooth # 2.

You asked the Plan to pre-approve the dental service. You say that you called member services to find an endodontist or permission to go out of network. You also say that you would like an exception to be made. The Plan denied your request. The Plan says root canal is not listed as a covered service. The Plan also says that dental services must be performed by a participating general dentist.

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 root canal is not among those covered under this benefit. Additionally, the Evidence of Coverage clearly states that dental services must be performed by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a root canal for tooth # 2.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shock reducing pylon (L5988) and a vacuum assisted suspension system (L5781) to be used with a lower limb prosthesis.
You asked the Plan to pre-approve a shock reducing pylon and a vacuum assisted suspension system. 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 must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a shock reducing pylon and a vacuum assisted suspension system. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation that the enrollee meets Medicare criteria for a shock reducing pylon (L5988) or a vacuum assisted suspension system (L8781). Records from the enrollee's treating medical provider do not address or document the medical necessity of a shock reducing pylon or of a vacuum assisted suspension system.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a shock reducing pylon and a vacuum assisted suspension system have not been met. Therefore, we decided that the Plan does not have to pre-approve a shock reducing pylon (L5988) and a vacuum assisted suspension system (L5781) to be used with a lower limb prosthesis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence wipes (A4335).

You asked the Plan to pre-approve incontinence supplies. You say that this will improve the enrollee's hygiene. The Plan denied your request. The Plan says this is not covered.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence wipes (A4335).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Avastin.

You asked the Plan to pre-approve Avastin. You say that the requested Avastin in addition to the chemotherapy regimen Gemcitabine, Docetaxel, and Pegfilgrastim she is already on is medically necessary. The Plan denied your request. The Plan says the requested Avastin in addition to the chemotherapy regimen Gemcitabine, Docetaxel, and Pegfilgrastim she is already on is not medically necessary.

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 Avastin. Our reviewer says that the requested Avastin in addition to the chemotherapy regimen Gemcitabine, Docetaxel, and Pegfilgrastim she is already on is not medically necessary. Our physician reviewer found the enrollee is with uterine sarcoma. Compendia and published, peer-reviewed medical literature states Avastin has no role in uterine sarcoma. In addition, Avastin has no role with chemotherapy. The requested Avastin is not medically necessary in this case.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Avastin have not been met. Therefore, we decided that the Plan does not have to pre-approve Avastin.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for eye refraction services received on August 11, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Medicare doesn't cover routine eye exams (eye refractions) for eyeglasses/contacts.

The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. 

The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for eye refraction services received on August 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures (D0431) provided August 13, 2021.
You asked the Plan to pay for the adjunctive pre-diagnostic test. You say that this was part of your surgery and should not be denied. The Plan denied your request. The Plan says this service is not covered under your 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 pay for the
adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures (D0431) provided August 13, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional hours of neuropsychological testing (96133, 96139).

You asked the Plan to pre-approve neuropsychological testing. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested services have not been met.

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 neuropsychological testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that you are asking for an excessive amount of the procedure beyond that which is approved under the Medicare rules. The enrollee has shown an impairment in functioning as documented. The enrollee has been showing difficulty with memory issues. Based on the records provided, the enrollee does not meet the criteria for additional neuropsychological testing.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the Plan does not have to pre-approve additional hours of neuropsychological testing (96133, 96139).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF 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 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 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. 

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 skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for a colonoscopy (45385) provided March 31, 2021.

You asked the Plan to waive the copayment for the colonoscopy. You say that the colonoscopy was a screening service and there should be no copayment. The Plan denied your request. The Plan says that a screening colonoscopy is only covered once every 24 months and the procedure performed was diagnostic in nature, therefore a copayment was applied.

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 does not say in clear and accurate terms how much you should expect to pay for the diagnostic colonoscopy. 

We looked at your contract with the Plan. While the Evidence of Coverage states that a copayment will be applied for a colonoscopy that is diagnostic in nature and not a screening colonoscopy, the Evidence of Coverage does not state the amount that is applied. The Plan contract does not clearly say how much enrollees must pay for a diagnostic colonoscopy. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copayment for a colonoscopy (45385) provided March 31, 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: 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. The Plan denied your request. The Plan says you do not need an intensive team to oversee your care.

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 physician reviewer found that you were admitted to the acute care hospital with recurrent falls. You are at a supervision assist level with upper body dressing, moderate assist for lower body dressing, and standby assist for toileting. You have your no rehabilitation nursing needs. At the current functional level, you do not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy.

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.