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

We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Actemra.
You asked the Plan to pre-approve Actemra. You say that Actemra is commonly used off-label for this purpose
and would be affordable for the enrollee. The Plan denied your request. The Plan says the denial of
authorization for this drug is correct, because the requested use of Actemra is not Food & Drug Administration
approved or supported by drug compendia.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
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 Actemra. Our reviewer says that the
enrollee does not meet the Medicare criteria for the requested use of Actemra. Our physician reviewer found
the enrollee does not have proven giant cell arteritis and has not had an opportunity to respond to the standard
of care doses of either steroids or methotrexate. The requested use of intravenous Actemra is not Food & Drug
Administration (FDA) approved for the enrollee's diagnosis. This use is not supported by one of the major drug
compendia or by clinical research that appears in a Medicare-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 Actemra have not been met. Therefore, we decided that the Plan does not have
to pre-approve use of Actemra
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7140) provided on June 14, 2021.
You asked the Plan to pay for the extraction (D7140). You say that the crown came off and could not be restored. You say that the booklet states coverage other procedures and now you have many expenses. The Plan denied your request. The Plan says the service is not a covered benefit.
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 extraction (D7140) provided on June 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided from May 12, 2021, to May 26, 2021.
You asked the Plan to pay for inpatient hospital care. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because coding and billing guidelines do not support the use of I50.33 on this claim.
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 I50.33. 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 this inpatient coding does not meet the Medicare criteria for payment. Our physician reviewer found physical examination was normal for the lungs and breathing and vitals were stable. I50.33 (acute on chronic diastolic heart failure) was used as a secondary diagnosis. Although chronic heart failure was an appropriate diagnosis for this enrollee based on the provided notes, there was no evidence that there was an acute exacerbation to justify the I50.33 diagnosis for this hospital course. 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 from May 12, 2021, to May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on March 8, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you had a telehealth visit and not a physical office visit. You say you would like your account corrected. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
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 $40
copayment for services obtain from a specialist, or under certain circumstances, treatment by a nurse
practitioner or physician's assistant or other non-physician health care professionals in a specialist's office.
You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner Services, Including Doctor's Office Visits" 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 specialist office visit provided on March 8, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have 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 the enrollee is an 83-year-old female with a past medical history of diabetes, hypertension, cardiomyopathy and dementia who presented to the acute hospital on August 21, 2021, with generalized weakness related to coronavirus. While this patient does require skilled therapy services, there is no documentation that the patient requires skilled nursing services. In addition, based on the medical records provided daily skilled services are not required. Therapy is recommended 2-3 times per week in the available records. This patient does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear more appropriate in this case due to her level of confusion, weakness and limited cooperation with 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a scooter.
You asked the Plan to pre-approve the scooter. You say that you require the scooter. The Plan denied your request. The Plan says the documentation does not support the necessity for a scooter.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that the documentation does not show you do not have a mobility deficit that impairs your participation in MRADLs, or your condition can be improved by a walker, cane or manual wheelchair or that you can safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit (G0439) and the electrocardiogram (93000) rendered by the out-of-network (OON) provider on May 17, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 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 the annual wellness visit (G0439) and the electrocardiogram (93000) rendered by the out-of-network (OON) provider on May 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture services to be performed by an out-ofnetwork
provider.
You asked the Plan to pre-approve acupuncture. You say that you have sciatica and pain in both of your legs
that you want relief from. The Plan denied your request. The Plan says the denial of authorization for this
service is correct, because you do not have chronic low back pain which is required for coverage of
acupuncture. he Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20
sessions per year.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of
the acupuncture services have not been met. Specifically, the record does not show that you have chronic low
back pain as a diagnosis. Therefore, we decided that the Plan does not have to pre-approve acupuncture
services to be performed by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 additional units of the bilateral injection of nerves innervating the sacroiliac joint coded as 64451.
You asked the Plan to pre-approve 2 additional units of bilateral injection services. You say that this is medically necessary. The Plan denied your request. The Plan says the denial of the additional units of code 64451 was correct.
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 2 additional units of CPT code 64451is not supported in the medical record. Specifically, coded 64451 and 64625 of nerves innervating the SI joint are reported only once regardless of the number of nerves injected or ablated.
Based on this information, we decided that Medicare rules for coverage of 2 additional units of bilateral injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve 2 additional units of the bilateral injection of nerves innervating the sacroiliac joint coded as 64451.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services coded as 36558, 77001, and 76937 provided on March 10, 2021.
You asked the Plan to pay for the medical services. You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says these claims have denied correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that if the minor surgery has a global surgery value of 010, separate payment is not allowed for postoperative procedures related to the surgery. In this case, the enrollee received minor surgery coded as 36581 on March 3, 2021. This procedure has a global surgery value of 010. In this case, the code billed 36558 on March 10, 2021, would not be separately payable since it is within the 10-day global surgery window. Regarding codes 77001 and 76937, payment cannot be made for these services since they are add-on codes to 36558. Since payment cannot be made for primary code 36558, these codes are also not eligible for payment. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded as 36558, 77001, and 76937 provided on March 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional days of substance abuse inpatient alcohol rehabilitation services from October 15, 2021, forward.
You asked the Plan to pre-approve additional days of substance abuse inpatient alcohol rehabilitation services. You say that you had a significant deterioration in mental status resulting in a higher risk of harm to yourself or others. The Plan denied your request. The Plan says there is insufficient evidence that further hospitalization is medically necessary.
The Plan must follow Medicare rules as listed in the Medicare rules section of this letter. 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 additional days of substance abuse inpatient alcohol rehabilitation services. Our reviewer says that the additional inpatient days from October 15, 2021, forward are not medically necessary. Our physician reviewer found that there was no documentation showing that you require the supervision and intensity of services which can only be found in the controlled environment of the hospital, or that only the hospital environment can assure the medical management or control of your concomitant conditions during the course of alcohol rehabilitation. It did not appear that active treatment was taking place from October 15, 2021, forward. It was not medically necessary and reasonable to have psychiatric care provided at the acute inpatient level rather than a lower-level care during the time in question. Based upon review the records provided, a longer period of alcohol rehabilitation from October 15, 2021, forward is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional days of substance abuse inpatient alcohol rehabilitation services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional days of substance abuse inpatient alcohol rehabilitation services from October 15, 2021, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain crown (D2740) and core build up (D2950) for tooth # 26.
You asked the Plan to pay for the dental services. You say that the services are medically necessary. The Plan denied your request. The Plan says porcelain crown is not listed as a covered service. The Plan says that core build up is not listed as a covered service either.
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 porcelain crown and core build up are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the porcelain crown (D2740) and core build up (D2950) for tooth # 26.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an osseous surgery (D4261), bone replacement graft of the first site in the quadrant (D4263), bone replacement graft of each additional site in the quadrant (D4264), and guided tissue regeneration (D4266).
You asked the Plan to pre-approve the osseous surgery, bone replacement grafts, and guided tissue regeneration. You say that these procedures would increase the positive prognosis for tooth #'s 14 and 15. You also say that if these services are not completed, these teeth will eventually need to be extracted, which will affect the enrollee's over all dental health. The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit package. edicare 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 an osseous surgery (D4261), bone replacement graft of the first site in the quadrant (D4263), bone replacement graft of each additional site in the quadrant (D4264), and guided tissue regeneration (D4266).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for digital analysis of electroencephalogram (EEG) (95957), nerve conduction studies (95907), and needle electromyography (95885) provided on October 23, 2020.

You asked the Plan to pay for diagnostic services. You say that the coding utilized is accurate and within the confines of prevailing industry standards. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the records do not support these codes.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 95957 is digital analysis of electroencephalogram. The CPT Code Manual definition of code 95907 is nerve conduction studies; 1-2 studies. The CPT Code Manual definition of code 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited.

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for diagnostic services. Our reviewer says that these codes do not meet the Medicare criteria for payment. Our reviewer found for code 95957, this procedure code is inappropriate to report for real-time monitoring, and no digital analysis was documented in the report. For code 95907, the technical report includes documentation of pedicle screw stimulation which is the incorrect code to report. Nerve conduction studies include measurement of amplitude, latency, and conduction velocity. For code 95885, as no nerve conduction studies were documented in the technical report this procedure is not covered, as it includes nerve conduction studies. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of diagnostic services have not been met. Therefore, we decided that the Plan does not have to pay for digital analysis of electroencephalogram (EEG) (95957), nerve conduction studies (95907), and needle electromyography (95885) provided on October 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of daratumumab.

You asked the Plan to pre-approve daratumumab. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the enrollee is reported to be intolerant of a protease inhibitor (Velcade) but this substitution is unacceptable and without additional details does not align with acceptable medical care in the enrollee's condition.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve daratumumab. Our reviewer says that the enrollee does not meet the criteria for the requested use of daratumumab. Our physician reviewer found the records show that the enrollee is intolerant to Velcade due to persistent leukopenia. The treating provider switched to daratumumab. Daratumumab is not an acceptable treatment as monotherapy.

This drug is used in combination with other anti-myeloma drugs and has been approved in the first line including in the relapsed/refractory clinical. The request failed to indicate clearly in what setting is this drug approval being sought. The requested use of daratumumab is not Food & Drug Administration (FDA) approved for this condition. Its use is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-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 daratumumab have not been met. Therefore, we decided that the Plan does not have to pre-approve use of daratumumab.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Colovantage testing.
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 testing is not covered.
The Plan must follow Medicare rules. Medicare rules say that sDNA testing other than Cologuard is noncovered.
We looked at the file and Medicare rules. The testing at issue is sDNA testing for colorectal cancer that is not
the Cologuard test. This testing is not covered by Medicare. Therefore, we decided that the Plan does not have
to pre-approve Colovantage testing.