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

We decided that the Plan does not have to pre-approve bronchoscopy with balloon (CPT code(s): 31651, 31648, 31649, and 31634), for the enrollee.
You asked the Plan to pre-approve the service. You say that the enrollee has a history of severe emphysema. You state management of the enrollee's symptoms has included long term oxygen therapy, inhaled and systemic steroids along with bronchodilators. The Plan denied your request. The Plan says bronchoscopy (tube to examine the airways) cannot be approved because endobronchial valve placement has not been medically proven to be effective.
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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has severe emphysema. The record indicates that the enrollee is recovering from Coronavirus (COVID-19) lung infection. The record submitted indicates that the enrollee is still undergoing evaluation and does not indicate that has failed standard treatment for their condition. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service at this time. 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 the service have not been met. Therefore, we decided that the Plan does not
have to pre-approve bronchoscopy with balloon (CPT code(s): 31651, 31648, 31649, and 31634), for the
enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from February 6, 20201, to February 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 the DRG was updated.
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.
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 services. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our physician reviewer found the
review indicates that the documentation supported an admission for further evaluation and treatment of a
urinary tract infection in an enrollee with a past medical history to include dementia, cerebrovascular accident
with left hemiparesis, hypertension, and atrial fibrillation. On the physical exam, the history and physical
documentation noted that the enrollee was alert, resting comfortably, and oriented to person. The review
indicates that the records did not support the coding of the DRG and diagnosis codes in this case.
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 services provided to the enrollee from February 6, 20201, to February 11, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided from July 19, 2021, to July 21, 2021.
You asked the Plan to pay for the outpatient hospital services. You say that the services that the enrollee received are not related to their hospice diagnosis. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
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 the outpatient hospital services provided from July 19, 2021,
to July 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for a manual push wheelchair for the enrollee.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says medically necessary care is available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral out-of-network for a manual push wheelchair for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a medical eye exam (92014) and an eye exam with photos (92250) provided on August 11, 2021.
You asked the Plan to reimburse you for a medical eye exam and eye exam with photos. You say that your vision policy states you receive up to $75 per year for an eye refraction and a routine eye exam. You are requesting reconsideration. The Plan denied your request. The Plan says the copayment you are being charged is correct.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that you receive a routine eye exam including an eye refraction once per calendar year. The Plan contract also says that you pay a $25 copayment for an eye exam at a specialist office for the diagnosis and treatment of diseases and injuries of the eye. We looked at the file and the Plan's rules. The records show you received a medical eye exam and an eye exam with photos with a specialist. The records also show that the Plan paid the allowed amount for a medical eye exam and an eye exam with photos. You have been asked to pay a $25 copayment for a medical eye exam. The EOC confirms $25 is the required copayment for this service. Based on this information, we decided that the Plan's rules for coverage of a medical eye exam and eye exam with photos have not been met. Therefore, we decided that the Plan does not have to reimburse you for a medical eye exam (92014) and an eye exam with photos (92250) provided on August 11, 2021
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services billed to the enrollee for date of service December 26, 2020.
You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request. The Plan says the medical records show the date of service was December 20, 2020 not December 26, 2020.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and the correct time and date information. In this case, the medical records and the claim stated date of service do not match. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for physician services billed to the enrollee for date of service December 26, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy and biopsy (45380) and tissue exam (88305) provided on February 25, 2021.
You asked the Plan to pay for the colonoscopy and biopsy and tissue exam. You say that there was confusion with coordination of benefits resulting in Traditional Medicare being billed as primary payer. You also say that prior authorization could not be obtained because you were informed post-discharge that the patient's primary insurance was with another plan. The Plan denied your request. The Plan says the enrollee was still a member of another Plan at the time of service, and she did not follow the rules of the Plan.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.
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 colonoscopy and biopsy and tissue exam.
Our reviewer says that these services were not medically necessary to be rendered out-of-network. Our
physician reviewer found the review has determined that the enrollee could have foreseen requiring the services
prior to leaving their service area. Our reviewer found that the records indicate that the care provided was not
medically necessary. Our physician reviewer also found that it would have been medically reasonable to delay
the services from February 25, 2021 when the enrollee received these services until March 1, 2021 or later.
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 colonoscopy and biopsy and tissue exam have not been met. Therefore, we
decided that the Plan does not have to pay for the colonoscopy and biopsy (45380) and tissue exam (88305)
provided on February 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Monoferric (J1437).
You asked the Plan to pre-approve Monoferric. You say that the requested drug 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 Monoferric. Our reviewer says that the requested treatment is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial of Infed before they will approve the requested drug. The requested drug 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 does not indicate that the enrollee has a contraindication to, or would have an adverse effect from, the Plan's preferred step-one alternative. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Monoferric have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Monoferric (J1437).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies, female external urinary collection device (A4328) bedside drainage bottle with or without tubing (A5102).
You asked the Plan to pre-approve incontinence supplies. You say that you need the items because it is difficult for you to walk due to being very weak and uses a wheelchair and walker. The Plan denied your request. The Plan says this item is not a covered benefit.
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 supplies, female external urinary collection device (A4328) bedside drainage bottle with or without tubing (A5102).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Evenity.
You asked the Plan to pre-approve Evenity. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because Evenity is limited to 12 monthly doses which the enrollee has already had.
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 Evenity. Our reviewer says that the enrollee does not meet the Medicare criteria for Evenity. Our physician reviewer found the record indicates that the enrollee has a diagnosis of age-related osteoporosis without current pathological fracture. The record indicates that a recent dual-energy X-Ray absorptiometry (DEXA) scan demonstrated osteopenia. The record does not support that the enrollee cannot tolerate other therapies or that they would be ineffective. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Evenity
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a kneeling scooter for the enrollee.
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your request. The Plan says
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 scooter. Our reviewer says that the requested scooter is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that the knee scooter at issue in this case meets Medicare criteria for being medically reasonable and necessary. The device has not been shown to be safe and effective in the Medicare population. 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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a kneeling scooter for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G Orthotic device (L8702).
You asked the Plan to pre-approve the orthotic device. You say that the MyoPro is a coverable device within the DME benefit category under Original Medicare. The Plan denied your request. The Plan says this item is considered experimental and investigational. There is insufficient evidence of its effectiveness.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. the medical records do not support that your medical providers initiated a recommendation of this device for you, or that you would be able to successfully use this device, as there was a lack of a trial of this device or a similar one. Based on this information, we decided that Medicare rules for coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G Orthotic device (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removal of residual tooth roots (D7250) for tooth #12.
You asked the Plan to pre-approve the removal of residual tooth roots. You say that the enrollee had tooth #12 extracted more than 6 months ago which is past the guideline time indicated in which root tip removal would have been included in previous extraction. You also say that the enrollee has a small root tip remaining in that area that needs to be removed. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.
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, extraction codes D7111, D7140, D7210, and D7250 are limited to one procedure per tooth per lifetime of the member. The record shows that the enrollee received a simple extraction (D7140) of tooth #12 on March 23, 2021 and the enrollee's extractions benefit for tooth #12 has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a removal of residual tooth roots (D7250) for tooth #12.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra solution.
You asked the Plan to pre-approve self-administered drug. You say that the enrollee switched to Xiidra in 2020 and has been stable using this medication. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
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 Xiidra solution.
Benefits for self-administered drug 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 pre-approve treatment with Aranesp (J0881).
You asked the Plan to pre-approve Aranesp. You say that the requested drug 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 Aranesp. Our reviewer says that the requested treatment is not medically reasonable and necessary in this case. Our physician reviewer found that the request does not meet criteria for use of Aranesp. Another agent is approved for therapy. Aranesp can be used after the other agent has been shown to be not tolerated or not indicated for medical reasons. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Aranesp (J0881).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the wheelchair accessory, power seat elevation system
You asked the Plan to pre-approve the wheelchair accessory. You say that please reconsider the original documentation provided for this K0861 and components needed to meet his current medical needs. The Plan denied your request. The Plan says the seat elevator does not serve a primary medical purpose and is statutorily non-covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the wheelchair accessory have not been met. Therefore, we decided that the Plan does not have to pre-approve the wheelchair accessory, power seat elevation system
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator to be provided by an out-of-network provider.
You asked the Plan to pre-approve a home ventilator. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not been met.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a home ventilator to be provided by an out-of-network provider.