Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulator (TENS) unit.
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says the medical records received did not indicate pain caused by osteoarthritis of the knee, and post-operative pain.
The Plan must follow Medicare rules. The rules say that TENS for chronic low back pain is only covered when the beneficiary is enrolled in an approved clinical study. 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 stimulator. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided records do not document enrollment in an approved clinical study. 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 stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulator (TENS) unit.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97139) and injections (J3411, J3415)
provided November 24, 2020.

You asked the Plan to pay for the therapy services and injections. 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. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that CPT code 97139, J3411, & J3415 is not supported in the medical record. Specifically, the record
does not specify what the unspecified therapy service provided was. Additionally, the injections were
administered as part of a nutria-pharmaceutical blend and are not separately billable.

Based on this information, we decided that Medicare rules for coverage of the therapy services and injections
have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (97139) and
injections (J3411, J3415) provided November 24, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve lumbar fusion at L4-5.
You asked the Plan to pre-approve lumbar fusion at L4-5. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve lumbar fusion at L4-5. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was being treated for radiculopathy, lumbar region. The enrollee presented with back pain that is progressively getting worse, but the injection gave him relief at about 50% to the point that the sciatica was not as intense. It is noted that the enrollee can sometimes walk a decent distance and not have a reaction, other times the enrollee has an issue with only a short distance. The enrollee is starting to get sciatica with sitting. There is documentation of failure of conservative measures. The enrollee has undergone previous L4-5 laminectomy with revision procedure as well. There was initial improvement post-surgery (the revision noted to have been completed on May 28, 2020), with recurrence of symptoms that are progressing. The enrollee is noted to be limited in his walking distance. The imaging studies corroborate grade 1 anterolisthesis of L4 on L5. While the flexion/extension x-rays are not noted to show instability; there is documentation evident regarding potential impending/inevitable temporary intra-operative instability. This includes the two previous laminectomy/decompression procedures at the same operative level. Therefore, the enrollee does meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar fusion at L4-5 have been met. Therefore, we decided that the Plan has to pre-approve lumbar fusion at L4-5.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the $200 copayments charged for multiple imaging
services provided on November 10, 2020.
You asked the Plan to waive or reduce these copayments. You say that you were not told there would be
copayments for the imaging services provided. The Plan denied your request. The Plan says these copayments
were charged based on the claim submitted by your provider and the Plan contract agreement. Maximus
overturned the Plans denial stating clear plan contract language had not been provided. The Plan requested a
reopen and provided additional information.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information (such as copayments, deductibles and coinsurance). Page 81 of the contract clearly
says that you must pay a $200 copayment for each outpatient diagnostic service other than those specifically
listed.
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 or reduce the $200 copayments charged for multiple imaging services provided on
November 10, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report.
You asked the Plan to pre-approve gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
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 gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has gastroesophageal reflux disease (GERD), bloating, gas, nausea, constipation,
weight loss, diarrhea, early satiety having failed laxatives, Zofran, bulking agents. Esophagogastroduodenoscopy and colonoscopy showed hiatal hernia, reflux esophagitis, polyps in colon, internal hemorrhoids, diverticulosis, redundant colon. Gastric emptying study showed delay. Present evidence does not clearly show benefit from this type of SmartPill gastrointestinal monitoring system as the enrollee clearly has signs and symptoms of dysmotility. Treatment options for this condition could be offered without the results of the test. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report have not been met. Therefore, we decided that the Plan does not have to pre-approve gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a medical alert system.
You asked the Plan to pre-approve a medical alert system. You say that you need this due to your weight and mobility. The Plan denied your request. The Plan says that this is not covered by the Plan or Medicare.
The Plan must follow Medicare rules. The rules say that telephone alert systems are excluded from coverage as these are emergency communications systems and do not serve a diagnostic or therapeutic purpose. Although this device may be appropriate, it is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a medical alert system.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Procrit (J0885).
You asked the Plan to pre-approve Procrit. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been met.
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 Procrit. Our reviewer says that the requested drug is not medically reasonable and necessary at this time. Our physician reviewer found that a request has been made for Procrit to treat the enrollee's iron deficiency anemia. The Plan requires that Retacrit be used. There is no evidence that the enrollee is allergic to or intolerant of Retacrit. There is no evidence that the enrollee has tried and not responded to Retacrit. There is no documentation as to why Retacrit would not be expected to be safe and effective 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 Procrit have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Procrit (J0885).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia, Injection, denosumab, 1 mg.

You asked the Plan to pre-approve Prolia, Injection, denosumab, 1 mg (J0897). You say that oral and IV bisphosphonates are contraindicated. The Plan denied your request. The Plan says the enrollee has not first tried and failed an oral bisphosphonate and zoledronic acid.

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 Prolia, Injection, denosumab, 1 mg (J0897). Our reviewer says that the patient has not tried and failed the required drug(s). Our physician reviewer found there is a reasonable argument to avoid use of an oral bisphosphonate due to the enrollee's reported severe gastroesophageal reflux disease. However, the provided records do not indicate that zoledronic acid would likely be less effective and/or likely have adverse effects for the patient. According to dosage recommendations in Drugdex/Micromedex, no dose adjustment is required for zoledronic acid in patients with a creatinine clearance of 35 ml/minute or greater. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia, Injection, denosumab, 1 mg (J0897) have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia, Injection, denosumab, 1 mg.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Velcade provided on February 3, 2021.
You asked the Plan to pay for the Velcade. You say that the Velcade provided on February 3, 2021 was medically necessary. The Plan denied your request. The Plan says the Velcade provided on February 3, 2021 was 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 pay for the Velcade. Our reviewer says that the Velcade provided on February 3, 2021 was not medically necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of mixed cryoglobulinemia. 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. No literature from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria are not satisfied. 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 the Velcade have not been met. Therefore, we decided that the Plan does not have to pay for the Velcade provided on February 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 20, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 laboratory services provided on January 20, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections with steroid injection and fluoroscopic guidance and contrast coded as 77003, 94760, J1030 and J1040.
You asked the Plan to pre-approve the injection services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says under Medicare guidelines, the request for facet joint injections with steroid injection and fluoroscopic guidance and contrast is not medically necessary.
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 injection services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the provided documentation, the enrollee had not yet tried and failed a full trial of conservative first line treatments for her lumbar pain and lumbar radiculopathy which is required prior to considering treatments for intra-articular pain in the spine for which these injections were intended. Therefore, this request for facet joint injections will be considered not medically necessary at this time. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections with steroid injection and fluoroscopic guidance and contrast coded as 77003, 94760, J1030 and J1040.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a debridement (11042, 11045) provided on November 17, 2020.

You asked the Plan to pay for the debridement. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 services at issue in this appeal. The Plan did not pre-approve the service
at issue. 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 a debridement (11042, 11045) provided on November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for interrogation device services provided on March 18, 2021 by an out-of-network provider.

You asked the Plan to pay for interrogation device services (93294, 93296). You say that the physician provided medically necessary services in good faith. The Plan denied your request. The Plan says prior authorization was not obtained as required.

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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 interrogation device services provided on March 18, 2021 by an out-of-network provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on March 2, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you would like to appeal this charge because you had critically low levels of potassium and magnesium The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that this claim was not denied, but you are being charged the appropriate cost sharing.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency room visits. You have been asked to pay a $90 copayment for the ER visit. 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 emergency room (ER) visit you had on March 2, 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 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 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 there are no services at the LTACH that the enrollee requires that are not already
available and covered at the current facility. Transfer to LTACH will be considered not medically necessary as
there is not a notable advantage at this time.
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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on July 23, 2020.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says due to the enrollee's hospice election at the time of service, this claim must be submitted
to Original Medicare first.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for medical services provided to the enrollee on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on June 11, 2021.
You asked the Plan to pay for this service. You say that this visit was referred by your primary care provider. The Plan denied your request. The Plan says your primary care office confirmed no referral was given for this service and it was neither urgent or emergent.
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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service at issue. Therefore, we decided that the Plan does not have to pay for out of network physician services provided on June 11, 2021.