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

We decided that the Plan does not have to pre-approve Aduhelm.

You asked the Plan to pre-approve Aduhelm. You say that the requested Aduhelm is medically necessary. The Plan denied your request. The Plan says the requested Aduhelm is not medically necessary.

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 Aduhelm. Our reviewer says that the requested Aduhelm is not medically necessary. Our physician reviewer found the documentation is insufficient to demonstrate that Aduhelm is reasonably expected to be safe and effective for the enrollee in this case. The documentation is insufficient to confirm a diagnosis of Alzheimer's disease in this enrollee. Three Mini-Mental State Examination (MMSE) evaluations in 2021 were consistent with normal cognition. The enrollee's Magnetic resonance imaging (MRI) suggests the presence of cerebrovascular disease, which is evidence of a mixed etiology for the enrollee's symptoms. In addition, it has not been shown that Aduhelm is at least as beneficial as existing and appropriate and available medically appropriate alternatives for this 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 Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 12001 billed for date of service February 27,
2021. You asked the Plan to pay for procedure code 12001. You say that you are billing for the professional
component for emergency room services. The Plan denied your request. The Plan says payment for 12001 is
bundled into the payment already made for code 12002.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 12001
is a column II code to column I code 12002. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for procedure code 12001 billed for date of service February 27,
2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services billed with modifier GL for date of service August 30, 2021.

You asked the Plan to pay for the ambulance services. You say that you billed this service correctly. The Plan denied your request. The Plan says the QL modifier was appended inappropriately.

The Plan must follow Medicare rules. Medicare rules say that in a case where the patient is pronounced dead after the ambulance is called but before the ambulance arrives at the scene, providers should report modifier QL. We looked at the medical records in this case. The records show that the ambulance was called at 15:48:27 on August 30, 2021, and was en route at 16:22:15. The ambulance arrived at the scene at 16:33:11. According to the records, the patient was not officially confirmed dead until 16:38, after the ambulance arrived at the scene. The Medicare rules state that the QL modifier is used when the patient dies prior to the ambulance's arrival at the scene. That was not the case here. Although the patient was in a body bag prior to arrival, the patient had not been officially confirmed deceased until after arrival. As such, the usage of the QL modifier is not appropriate in this case.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services billed with modifier GL for date of service August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine you received on April 26, 2021.

You asked the Plan to pay for the shingles vaccine. You say that you believe you were charged twice for this vaccine. The Plan denied your request. The Plan says this is not covered under your medical benefits. The Plan has provided you with information regarding how to submit your claim under your Part D benefits.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on April 26, 2021.

Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on August 9, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services
were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion
therapy rendered on August 9, 2021.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power scooter you purchased on July 7, 2021.

You asked the Plan to pay for the power wheelchair. You say that you were told that this item is covered 80% by the Plan. You stated that you followed the Plan instructions for submitting this claim. The Plan denied your request. The Plan says this item is not covered because you only need it outside of the home.

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. The letter of medical necessity submitted by your doctor says that you need this item to go to the grocery store and to get to your doctor appointments, both of which are 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 pay for the power scooter you purchased on July 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Erleada and Firmagon in combination.
You asked the Plan to pre-approve Erleada and Firmagon in combination. You say that Erleada and Firmagon
in combination are medically reasonable and necessary. The Plan denied your request. The Plan says Erleada
and Firmagon in combination are not medically reasonable and 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 Erleada and Firmagon in combination.
Our reviewer says that Erleada and Firmagon in combination are not medically reasonable and necessary. Our
physician reviewer found the requested use of Erleada and Firmagon is not FDA-approved for the enrollee's
diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a
CMS-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Erleada and Firmagon in combination have not been met. Therefore, we
decided that the Plan does not have to pre-approve Erleada and Firmagon in combination.
Appeal type: Practitioner Services
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules state that for codes billed for epidural steroid injections for pain management, the medical records
must include the legible signature of the physician or non-physician practitioner responsible for and providing
the care to the patient. In addition, the medical records must document the medical necessity for the blocks
with the pre and post percent pain relief achieved immediately post-injections. You can find this rule at
Wisconsin Physician Service Insurance Company Local Coverage Article A58777 entitled Billing and Coding:
Epidural Steroid Injections for Pain Management.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. We looked at the file and Medicare rules. The single medical record provided is not signed. In addition, the
medical record does not document the pre and post injection percent pain relief. Based on this information, we
decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided
that the Plan does not have to pay for procedure code 62320 billed for date of service September 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 70450 and 99053 billed for date of service
September 16, 2021.
You asked the Plan to pay for procedure codes 70450 and 99053. You say that the patient had multiple exams
on this date of service. The Plan denied your request. The Plan says procedure code 70450 is not separately
payable when billed with 70450 and 70496. The Plan also says that procedure code 99053 is never separately
payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450
is a column II code to column I code 70450 and 70496. This claim has not been billed with an appropriate
modifier to bypass the edit. In addition, Medicare rules say that payment for codes with a status indicator of B
are always bundled into payment for other services. Procedure code 99053 has a status indicator of B on the
Medicare Physician Fee Schedule. Based on the claim submitted, Medicare billing criteria have not been met.
Therefore, we decided that the Plan does not have to pay for procedure codes 70450 and 99053 billed for date
of service September 16, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 62320 billed for date of service August 30, 2021.

You asked the Plan to pay for procedure code 92320. You say that these services were billed appropriately and should be paid. The Plan denied your request. The Plan says you have not provided medical records to support the medical necessity of these services.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

Despite multiple requests by the Plan, you have not submitted medical records to show that the denied services were medically necessary. Without such records, we cannot determine if the services are payable. Based on this information, we decided that Medicare rules for coverage of procedure code 92320 have not been met.

Therefore, we decided that the Plan does not have to pay for procedure code 62320 billed for date of service August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for dates of service
October 25, 2020, and November 17, 2020.
You asked the Plan to pay for procedure codes 99100 and 99140. You did not provide an argument with your
appeal request. The Plan denied your request. The Plan says these codes are always bundled and never
separately payable.
The Plan must follow Medicare rules. Medicare rules say that payment for codes with a status indicator of B is
always bundled into payment for other services. Both codes 99100 and 99104 have a status indicator of B on
the Medicare Physician Fee Schedule, so no separate payment can be made for these codes. Based on this information, we decided that Medicare rules for coverage of procedure codes 99100 and 99140
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 99100 and
99140 billed for dates of service October 25, 2020, and November 17, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the admission is not medically necessary.
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 these services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found you were admitted to the hospital on
February 10, 2022 with a fall. You were treated in the emergency department (ED) for a spine fracture and
bruising and discharged home. You were seen for a follow up visit on February 11, 2022 and referred for a
possible spine surgery. You are noted to be weak and unsteady but no detailed evaluation by physical or
occupational therapy is provided. You have no skilled nursing needs. You have skilled therapy needs but do not
require skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an
inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) admission
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the requested semi-electric
hospital bed is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet
criteria for a semi-electric hospital bed.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered
medically necessary when the patient:
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND
3. Requires frequent changes in body position and/or has an immediate need for a change in body position.
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 semi-electric hospital bed. Our
reviewer says that the enrollee does not meet criteria for a semi-electric hospital bed. Our physician reviewer
found the documentation does not clearly reveal that enrollee's condition has failed positioning of the bed in
ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The
documentation does not support a need for frequent or an immediate change in body position or special
attachments that cannot be fixed on an ordinary bed. The enrollee is back at baseline oxygen that he was on
prior to hospital admit. There are no objective skin lesions on the physical examination that support he has 3
bed sores and need position changes. He has no signs of aspiration. The request for a semi-electric hospital bed
is not medically necessary for this 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 a semi-electric hospital bed have not been met. Therefore, we decided that the
Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 14 home physical therapy visits.
You asked the Plan to pre-approve 14 home physical therapy visits. You say that continued skilled therapy is
necessary to address her deficits, decrease her fall risk, improve safety in functional mobility and instruct her to
correctly perform home exercises. You say that she is unable to correctly complete the home exercises and
skilled intervention is necessary to improve. The Plan denied your request. The Plan says 4 visits were
approved, and additional visits are not medically necessary. The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve 14 home physical therapy visits. Our
reviewer says that the documentation does not support that the member requires additional skilled rehab
services. Our physician reviewer found that the member has been medically stable without any recent
exacerbations of chronic medical problems or hospitalizations.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 14 home physical therapy visits have not been met. Therefore, we decided that
the Plan does not have to pre-approve 14 home physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on July 15, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the OON lab services. You say that these services were medically necessary. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.

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 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 lab services provided on July 15, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Jakafi tablets.
You asked the Plan to pre-approve Jakafi tablets. You say that you would like the Plan to reconsider their
denial. The Plan denied your request. The Plan says Jakafi tablets are not covered under the enrollee's Medicare
Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Jakafi tablets. Benefits for Jakafi tablets may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit (G0439) provided on September 9, 2021.
You asked the Plan to pay for the annual wellness visit. You say that you would like reconsideration because you did not know that the first appointment was an annual wellness visit. The Plan denied your request. The Plan says you have exhausted the benefit for this calendar year.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months.
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the annual wellness visit (G0439) provided on September 9, 2021.