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

We decided that the Plan does not have to pre-approve Cequa Solution 0.09%.
You asked the Plan to pre-approve Cequa Solution 0.09%. You say that Xiidra and Restasis have been tried
with no improvement. The Plan denied your request. The Plan says Cequa is considered a Medicare Part D
benefit and the enrollee does not have Medicare Part D prescription drug coverage with the Plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Cequa Solution 0.09%.
Benefits for Cequa Solution 0.09% 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 pre-approve endoskeletal ankle foot system, microprocessor-controlled feature, dorsiflexion and/or plantar flexion control, includes power source (CPT code L5973) and flexible protective outer surface covering system (CPT code L5962).  You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the request for a K3 microprocessor ankle foot system (L5973) does not meet Medicare criteria as reasonable and necessary. The Plan states there is no documentation of unusually harsh environmental situations for which a specialized lower limb prosthetic cover (L5962) is required and for which the approved standard prosthetic cover (L5704) would be insufficient.  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 DME. Our physician reviewer found your physician provides no description of activities that cannot be met with a mechanical K3 foot. The notes do not show why a mechanical K3 foot, which is less prone to wear, corrosion and water damage, will not meet your needs. The requested K3 microprocessor ankle foot system (L5973) exceeds your needs and cannot be covered. The review has determined that the prosthetic leg, other parts, and custom shaped protective cover, below knee (CPT code L5704) are not medically necessary or reasonable.  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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve endoskeletal ankle foot system, microprocessor-controlled feature, dorsiflexion and/or plantar flexion control, includes power source (CPT code L5973) and flexible protective outer surface covering system (CPT code L5962).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve laryngoscopy services (31572 and 31541) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve laryngoscopy services. You say that it is medically necessary for these services to be provided by an OON provider. The Plan denied your request. The Plan says there are in-network providers available to provide the medical services the enrollee requires.  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 laryngoscopy services (31572 and 31541) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Glassia.  You asked the Plan to pre-approve Glassia. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Glassia is not covered under the enrollee's Medicare Part B benefit when dispensed by a pharmacy.  The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.  In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be administered through home health care. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Glassia.   Benefits for Glassia 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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a comprehensive electrophysiologic evaluation provided on April 15, 2021.  You asked the Plan to waive the coinsurance for the comprehensive electrophysiologic evaluation. You say that you feel that this was a surgical procedure and should only have a $350 copayment. The Plan denied your request. The Plan says the correct coinsurance was applied.  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 20% coinsurance for outpatient diagnostic tests and procedures.   You have been asked to pay $4,357.75, which is less than 20% of the allowed amount for the comprehensive electrophysiologic evaluation ($23.201.74 allowed amount x 20% coinsurance = $4,640.35).  The comprehensive electrophysiologic evaluation falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 coinsurance for a comprehensive electrophysiologic evaluation provided on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (62320) provided on August 2, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the required clinical records were not submitted.
The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing the care to the patient. In addition, the procedure report should clearly document the indications and the medical necessity for the blocks along with the pre-and-post-percent pain relief achieved immediately post-injection. The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. 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 the services (62320) provided on August 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography, head or brain (70450) and radiologic
examination, chest (71045) provided October 17, 2021.
You asked the Plan to pay for the diagnostic services. You say that the enrollee had multiple exams on this date
of service. Attached reports to support level of service. Please reconsider for processing. The Plan denied your
request. The Plan says this claim is considered to be an exact duplicate of the claim already paid.
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 find that CPT code 70450 and 71045 is not supported in the medical record. Specifically, the
records show that these services have already paid for by the Plan on 10/27/2021 and 10/31/2021. Based on this
information, we decided that Medicare rules for coverage of the diagnostic services have not been met.
Therefore, we decided that the Plan does not have to pay for computed tomography, head or brain (70450) and
radiologic examination, chest (71045) provided October 17, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Evenity.  You asked the Plan to pre-approve Evenity. You say that the enrollee is in severe pain. The Plan denied your request. The Plan says the enrollee has not tried any of the preferred agents.   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 Evenity. Our physician reviewer found that the enrollee has osteoporosis. Evenity was requested as a new start medication. The Plan requires a trial of Forteo before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug. There is no documentation provided indicating that the plan's required drug would likely be less effective or have adverse effects for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to pre-approve Evenity.
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 these services are medically necessary. The Plan denied your request. The Plan says that your wound care is not complex and does not require daily doctor visits or specialty nursing services.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. You appear to be improving and do not require complex wound care services. You should only require short-term additional acute care services that may be continued safely at the current facility for now. You do not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99000 billed for date of service July 27, 2021.
You asked the Plan to pay for procedure code 99000. You say that you have provided records to have this claim reconsidered. The Plan denied your request. The Plan says this is a bundled service that is not separately payable. The Plan must follow Medicare rules. Medicare rules say that codes given a status indicator of "B" are always bundled into payment for other services. Procedure code 99000 has a status indicator of "B. Therefore, we decided that the Plan does not have to pay for procedure code 99000 billed for date of service July 27, 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 you are ready for discharge and would benefit from LTACH level of care to return to prior level of functioning. The Plan denied your request. The Plan says you are receiving appropriate in-patient acute care and do not require transfer to an LTACH.  

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that you are stable and improving and should only require short-term additional acute care services that can be safely administered at the current facility. You do not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be considered when treatment has completed.  

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic radiology services and Part B
prescription drugs injection, bevacizumab, provided on July 22, 2021.

You asked the Plan to waive the copayment for diagnostic radiology services and Part B prescription drugs.
You say that you should only have a $45.00 specialist copayment and should not be charged a $31.53
copayment for the diagnostic test or a $13.84 coinsurance for the injection, bevacizumab. The Plan denied your
request. The Plan says a $31.53 copayment was applied towards the member's diagnostic tests copayment. As
the allowed amount for the diagnostic radiology services was less than the copayment of $50.00 as indicated in
the Evidence of Coverage the member was only charged in the amount of $31.53. An allowed amount of
$69.19, the Plan paid $55.35; a $13.84 which is the 20% coinsurance for Medicare Part B prescription drugs
that was applied.

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 $50
copayment for diagnostic tests and a 20% coinsurance for Part B prescription drugs for Outpatient Diagnostic
Tests and Therapeutic Services and Supplies-Medicare-covered outpatient diagnostic tests. Medicare Part B
Prescription Drugs.

You have been asked to pay less than the $50 copayment for diagnostic tests and you have been asked to pay a
20% coinsurance for Part B prescription drugs. The diagnostic radiology services falls within the Outpatient
Diagnostic Tests and Therapeutic Services and Supplies-Medicare-covered outpatient diagnostic tests benefit
category. The Part B prescription injection, bevacizumab, falls within the Medicare Part B Prescription Drugs
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 diagnostic radiology services
and Part B prescription drugs injection, bevacizumab, provided on July 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Combigan drops.
You asked the Plan to pre-approve Combigan. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Combigan drops.
Benefits for Combigan 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: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve periodontal scaling and root planing - four or more teeth per 
quadrant: LR, LL (CPT code D4341 x2. We decided that the Plan does not have to pre-approve periodontal 
scaling and root planing - four or more teeth per quadrant: UR, UL (CPT code D4341 x2). 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan says 
that the enrollee's tooth must have noticeable bone loss or show on an x-ray that there is a hard substance build 
up on the root of the tooth. The Plan states the enrollee's x-rays did not show that they have these issues.
We decided that the Plan has to pre-approve periodontal scaling and root planing - four or more teeth per 
quadrant: LR, LL (CPT code D4341 x2. 
The lower left quadrant shows four or more areas of abnormal pocketing along with noted loss of bone in the 
range of 15%. The lower left quadrant would have medical necessity for scaling and root planing due to the 
loss of alveolar bone and pocketing in excess of 4 mm on four or more teeth.
The lower right quadrant has four or more teeth with abnormal pocketing and at least four teeth that show 
notable bone loss on x-rays. Under the D4341 code, this quadrant would have necessity for scaling and root 
planing. Therefore, we decided that the Plan has to pre-approve periodontal scaling and root planing - four or 
more teeth per quadrant: LR, LL (CPT code D4341 x2. 
We also decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or 
more teeth per quadrant: UR, UL (CPT code D4341 x2).
The upper left quadrant has four teeth with pocketing in excess of 4 mm however there is noted bone loss only 
on the molars, which would be two teeth. As the code for D4341 allows only for four or more teeth in a 
quadrant, there would be no necessity for the requested procedure in the UL quadrant under D4341.
The upper right quadrant has four or more areas of pocketing in excess of 4mm, however there are only three 
areas that exhibit notable bone loss, around teeth #2-4. As code D4341 is reserved for areas that involve four or 
more teeth, there would not be necessity for the requested treatment under D4341. Therefore, we decided that 
the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth per quadrant: 
UR, UL (CPT code D4341 x2).
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that your high acuity needs cannot be managed in a lower level of care. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found you do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and are only able to be furnished safely and effectively 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 pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the continuation of the negative pressure wound therapy electrical pump (E2402, A6550).  You asked the Plan to pre-approve the continuation of the negative pressure wound therapy electrical pump. You say that the requested equipment continues to be medically necessary. The Plan denied your request. The Plan says based on Medicare rules, the enrollee has exceeded the maximum coverage time for this device of 4 months.  The Plan must follow Medicare rules. Medicare rules say that a NPWT pump and supplies will be denied as not reasonable and necessary when 4 months have elapsed using a NPWT pump in the treatment of the most recent wound.  We looked at the file and Medicare rules. In this case, the enrollee has exhausted the coverage time for the NPWT pump and supplies. Based on this information, we decided that Medicare rules for coverage of the continuation of the negative pressure wound therapy electrical pump have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of the negative pressure wound therapy electrical pump (E2402, A6550).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection rendered on September 27, 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. Medicare rules say that for code 62320 to be covered, certain documentation requirements must be met.

The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. 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 the injection rendered on September 27, 2021.