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

We decided that the Plan does not have to pre-approve Aranesp.
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 step therapy requirement is not 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has anemia of
myelodysplastic syndrome. He has not tried and failed the Plan's required drug, Retacrit. The records do not
show that the required drug would be contraindicated or less effective; therefore, Aranesp is not reasonable or
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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Aranesp.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) services provided from March 6, 2021, to April 4, 2021.

You asked the Plan to pre-approve the SNF services. You say that the enrollee meets criteria for SNF care. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient SNF level of care.

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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that as of March 6, 2021, the member did not require any skilled nursing or rehab services on a daily basis. She was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living (ADLs). The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care as of March 6, 2021. The enrollee did not have any parental medications, complex wound care or nutrition given via a feeding tube. The member received skilled care and improved; however, her function had plateaued by March 6, 2021, and she did not require any further inpatient skilled rehab services. The enrollee's function was at or near her prior level of function and she could be discharged to a lower level of care for further services. As of March 6, 2021, the enrollee required custodial services. The denial for further inpatient skilled care is upheld.

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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) services provided from March 6, 2021, to April 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide reimbursement for the medical equipment provided by a chiropractor on November 23, 2020.

You asked the Plan to provide reimbursement for the medical equipment. You say that you feel that at least the Medicare amount should be paid. The Plan denied your request. The Plan says this is not covered when purchased from this type of provider.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that you purchased medical equipment from this chiropractor. Medicare does not cover medical equipment from this type of provider as coverage is limited to manual manipulation of the spine. Therefore, we decided that the Plan does not have to provide reimbursement for the medical equipment provided by a chiropractor on November 23, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the skilled nursing facility (SNF) care provided from September 1, 2020, through September 09, 2020, billed with Health Insurance Prospective Payment System (HIPPS) code GDPF1.

You asked the Plan to pay for the SNF services as billed. You say that the enrollee's functional performance was correctly reported per Medicare rules. The Plan denied your request. The Plan says that the clinical documentation provided does not support the function score as coded on the Minimum Data Set assessment.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided a specific issue with the documentation of the enrollee's prior functional status. The rationale is a broad statement that just indicates that the documentation does not support all the section GG payment items. We have reviewed the Section GG items and find that these are documented by a staff member at the facility. The Plan does not point to any specific function as incorrectly documented. As such, we are unable to review whether the Plan's denial argument has merit. We find that the denial of payment for the billed code is not supported. Therefore, we decided that the Plan has to pay for the skilled nursing facility (SNF) care provided from September 1, 2020, through September 09, 2020, billed with Health Insurance Prospective Payment System (HIPPS) code GDPF1.

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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT).

You asked the Plan to pre-approve IGRT. You say that IGRT is medically necessary, is needed in order to ensure that treatment covers the symptomatic lesion and is not given to her nearby cancer-free organs. You say that oblique files and complex blocking was used to spare nearby organs at risk, justifying the requested treatment. The Plan denied your request. The Plan says there is no current research showing that the enrollee's type of cancer responds better to the requested type of treatment than complex isodose treatment.

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 IGRT. Our reviewer says that IGRT is not considered medically reasonable and necessary in this case. Our physician reviewer found for the palliative treatment of bone metastases, the use of IGRT is generally considered not medically necessary outside of a medically plausible rationale. In this case, the intent is clearly palliative, and it is not clear what benefit IGRT would afford. It seems as though IGRT is simply being used as routine practice, as there does not seem to be any exceptional circumstances with this patient necessitating the need for IGRT. IGRT is not an accepted standard of care for routine use in the palliative treatment of bone metastases. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT).
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. You say that you cannot keep the pain in your feet down without 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for radiofrequency ablation (64625) provided on March 22, 2021.
You asked the Plan to pay for radiofrequency ablation. You say that the requested service was medically necessary for the overall care of the enrollee. The Plan denied your request. The Plan says the service requested is considered not medically necessary/investigational whether performed using traditional, cooled, or pulsed radiofrequency.
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 pay for radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is deemed experimental/investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pay for radiofrequency ablation (64625) provided on March 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.

You asked the Plan to pre-approve the Vertiflex procedure. You say that this request is medically reasonable and necessary. The Plan denied your request. The Plan says the requested procedure is experimental/investigational.

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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed.

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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a stair glide.

You asked the Plan to pay for a stair glide. You say that you have multiple health issues and your bedroom is on the second floor of your home. The Plan denied your request. The Plan says this item is not covered by Medicare because it is a convenience item that is not primarily medical in nature.

The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. 

While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a stair glide.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the OVA1 proteomic assay provided on November 9,
2020.

You asked the Plan to pay for the OVA1 testing. You say that this testing is covered by the local Medicare
contractor. The Plan denied your request. The Plan says this testing is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that biomarker testing may be covered when certain
criteria are met. OVA1 testing is limited to tests done in accordance with the FDA label.

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 OVA1 testing. Our reviewer says that the
testing provided is not considered reasonable and necessary. Our physician reviewer found the enrollee has
findings of right complex ovarian cyst. OVA1 is FDA-cleared for detecting ovarian cancer risk in those who
are planning surgery for a pelvic mass. There is no noted plan for surgery, and the enrollee has a cyst not a
mass.

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 OVA1 testing have not been met. Therefore, we decided that the Plan does
not have to pay for the OVA1 proteomic assay provided on November 9, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the head and neck ultrasound and the breast ultrasound provided on February 2, 2021, and February 18, 2021.
You asked the Plan to waive the copayments for the head and neck ultrasound and the breast ultrasound. You say that you disagree with the charges for the ultrasounds. 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 $160 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in an in-network physician's office or at an in-network free-standing facility (such as a radiology center or medical clinic). You have been asked to pay a $207.02 copayment for the head and neck ultrasound and the breast ultrasound. The head and neck ultrasound and the breast ultrasound fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Copayment
Member Liability
February 2, 2021
Head and neck ultrasound
$118.81
$160
$118.81
February 18, 2021
Breast ultrasound
$88.21
$160
$88.21
Total
$207.02
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 copayments for the head and neck ultrasound and the breast ultrasound provided on February 2, 2021, and February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the intravenous infusion therapy provided on May 24, 2021.
You asked the Plan to waive the copayment for the intravenous infusion therapy. You say that you have never been charged for intravenous therapy before. You say you are on a fixed income and cannot afford to pay it. 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 $150 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.
You have been asked to pay a $150 copayment for the intravenous infusion therapy. The intravenous infusion therapy falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 intravenous infusion therapy provided on May 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the bilateral extremity angiography rendered on September 10, 2020.

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 procedure code 75716 is not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. 

The provider submitted a claim for procedure codes 75716 (bilateral extremity angiography) and 37227 (endovascular revascularization). Code 75716 is a column II code with a modifier indicator of 1 when billed with column I code 37227. Code 75716 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the bilateral extremity angiography rendered on September 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services rendered 
from February 12, 2021 to February 19, 2021. 
 
You asked the Plan to pay for the LTACH services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the requested LTACH care was 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 pay for the LTACH services. Our reviewer says that 
the requested LTACH care was not medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital on January 12, 202 with an incarcerated umbilical hernia. He underwent open repair 
with resection of small bowel. 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 and able to be furnished safely and 
effectively only on an inpatient basis. 
 
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 pay for long term acute care hospital (LTACH) services rendered from  
February 12, 2021 to February 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this device is medically necessary. The Plan denied your request. The Plan says this is considered experimental/investigational.
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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex procedure is experimental. More research is needed before coverage can be approved.
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 23, 2020.
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 were billed incorrectly.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in a nursing home setting and should have been billed with POS code 32. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 23, 2020.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided December 30, 2020 to February 5, 2021.

You asked the Plan to pay for the inpatient services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

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 A41.1, defined as sepsis due to other specified Staphylococcus. We asked our coding 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 inpatient services. Our reviewer says that the documentation does not support the DRG billed. Our coding reviewer found diagnosis A41.1, sepsis due to other specified staphylococcus, billed as a primary diagnosis is not supported in the medical documentation submitted. Therefore, the charges associated are not eligible for reimbursement. 

We looked at this coder'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 the inpatient services provided December 30, 2020 to February 5, 2021.