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

 We decided that the Plan does not have to pre-approve Tepezza.  You asked the Plan to pre-approve Tepezza. You say that the mediation is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.   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 Tepezza. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the review has determined that the documentation does not support that the Tepezza is medically reasonable and necessary for the enrollee. The documentation does not support that the Tepezza is safe and effective 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 Tepezza have not been met. Therefore, we decided that the Plan does not have to pre-approve Tepezza.
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve Alimta for use with carboplatin.  You asked the Plan to pre-approve the use of Alimta. You say that this should be approved. The Plan denied your request. The Plan says that Alimta is not supported in this situation.  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 the use of Alimta. Our reviewer says that the requested use of Alimta is considered medically necessary in this case. Our physician reviewer found the enrollee has adenocarcinoma of the lung with an epidermal growth factor receptor (EGFR) mutation on exon 19. The enrollee has had disease progression on Tagrisso. Review of the Medicare-approved compendia shows support of the use of carboplatin and Alimta for the enrollee's condition.  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 use of Alimta have been met. Therefore, we decided that the Plan has to pre-approve Alimta for use with carboplatin.   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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for services provided to the enrollee on October 5, 2020 and billed under codes 95885-XU, 95885, and 95910.   You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. 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 codes 95885-XU, 95885, and 95910. Our reviewer found for code 95885; nerve conduction studies are included when reporting this code.  As nerve conduction studies were not documented as performed, this code would not be covered. This is the same issue with code 95885. For code 95910; the technical report documents "pedicle screw stimulation", this is not the correct code to report for nerve conduction studies which include measurement of latency, amplitude, and conduction velocity.  This is not documented in the technical report, and therefore would not be covered. Medicare billing criteria are not met. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the codes in question are not met. Therefore, we decided that the Plan does not have to pay for services provided to the enrollee on October 5, 2020 and billed under codes 95885-XU, 95885, and 95910.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia.  You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy requirements 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 Prolia. Our reviewer says that the requirements for coverage of Prolia have not been met. Our physician reviewer found the Plan requires a history of osteoporosis-related fracture or a trial of zoledronic acid before they will approve the requested drug. There is no documentation provided indicating that the enrollee has a history of osteoporosis-related fracture, that the enrollee has tried zoledronic acid, or that zoledronic acid 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a manual wheelchair.  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 item is not covered.  The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.  The file shows that the enrollee has a power scooter. The power scooter serves the same purpose as the requested manual wheelchair. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve handrails/grab bars.  You asked the Plan to pre-approve handrails/grab bars. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says handrails/grab bars are not covered by Medicare or the Plan.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve handrails/grab bars.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and back-up camera (K0108).  You asked the Plan to pre-approve a power seat elevation system and back-up camera. You say that you need these items to be able to get out of bed. The Plan denied your request. The Plan says these items are not medical in nature.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules also specify that power seat elevation feature (E2300) is non-covered because it is not primarily medical in nature.   The items at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and back-up camera (K0108).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the head or brain (70450).  You asked the Plan to pre-approve a CT scan. You say that this is medically necessary. The Plan denied your request. The Plan says the previous imaging the enrollee received was sufficient.  The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a CT scan. Our reviewer says that the requested CT is not medically necessary. Our physician reviewer found given that the prior imaging study had returned negative, there is nothing to prompt the need for repeat evaluation at this time.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the head or brain (70450).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an oral appliance to be rendered by the out-of-network (OON) provider.  You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested item.  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 item at issue in this appeal. We found no exception that would require the Plan to pre-approve this item. Therefore, we decided that the Plan does not have to pre-approve an oral appliance to be rendered by the out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Dexcom G6 continuous glucose monitor.  You asked the Plan to pre-approve the Dexcom G6 continuous glucose monitor. You say that this item is medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage of this device have not been met.  The Plan must follow Medicare rules. Medicare rules say that a Plan may limit DME items to preferred items with exceptions listed in the Medicare rules section.   We looked at the file and Medicare rules. In this case, there is no evidence that the Plan's preferred brand would be less effective than the requested item. Based on this information, we decided that Medicare rules for coverage of the Dexcom G6 continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve the Dexcom G6 continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for subsequent hospital care services provided to the enrollee on February 9, 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 providers are required to furnish necessary information to the health plan when requested.  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 99233 is "Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit."  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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the documentation includes a subsequent hospital care for date of service February 9, 2021, however per 95 guidelines documentation submitted supports CPT 99231 (History - Problem focused; Exam - Expanded problem focused; Medical Decision Making - Straightforward). The documentation also includes a claim (number KLC 02763018-22) with CPT 99233GC billed twice for same date of service.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for subsequent hospital care services provided to the enrollee on February 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for services you received from an inpatient rehabilitation hospital from March 20, 2021, to April 7, 2021.  You asked the Plan to waive the copayment for the inpatient rehabilitation hospital services. You say that you do not want to pay this copayment because these services would not have been needed if you hadn't gotten COVID-19. The Plan denied your request. The Plan says you have not been charged a copayment for your acute hospital stay from February 25, 2021, to March 20, 2021. However, the Plan says that you have been charged the copayment for the inpatient rehabilitation hospital services from March 20, 2021, to April 7, 2021, correctly.    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 $345 copayment per day for days 1-5, and a $0 copayment thereafter for inpatient hospital care (including inpatient rehabilitation care).   Records show that you were in the inpatient rehabilitation hospital for 16 days. You were charged a $345 copayment per day for the first 5 days, for a total of $1725. You were not charged a copayment for the remaining days. This means that you have been asked to pay the correct amount based on your contract with the Plan. There is no provision in your contract for a waiver of this amount, even if the stay was COVID-19-related. 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 services you received from an inpatient rehabilitation hospital from March 20, 2021, to April 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 12 additional physical therapy visits.  You asked the Plan to pre-approve 12 additional physical therapy visits. You say that you are requesting an appeal to continue physical therapy twice a week for 6 weeks for a total of 12 visits. The Plan denied your request. The Plan says additional physical therapy is not medically necessary.   The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.  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 12 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the documentation does not support coverage for additional 12 physical therapy visits. Our reviewer says that the unique skills of a professional therapist are not required to provide ongoing treatment.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 12 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 additional physical therapy visits.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued care in a skilled nursing facility (SNF).  You asked the Plan to pre-approve continued SNF care. You say that you have only been going to the therapy room for one week. You say that your wound care is still in progress and has hampered your ability to regain strength. You also say that you need to be able to regain your strength in order to return to an assisted living facility. The Plan denied your request. The Plan says there is no evidence of progression toward functional goals despite therapy.  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 continued SNF care. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. While the enrollee had skilled therapy needs, they did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued SNF care have not been met. Specifically, the file does not show that the enrollee requires daily skilled services. Therefore, we decided that the Plan does not have to pre-approve continued care in a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the Denosumab injection provided on August 9, 2021.  You asked the Plan to waive the coinsurance for the injection. You say that you thought the treatments were covered in full based on the doctor's office information and the letter you received. 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 Medicare Part B prescription drugs.      You have been asked to pay 20% of the allowed amount for the injection ($1205.40 allowed amount x 20% coinsurance = $241.08). The injection 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 coinsurance for the Denosumab injection provided on August 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Repatha Sure.  You asked the Plan to pre-approve Repatha Sure. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.  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 Repatha Sure.   Benefits for Repatha Sure 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 the Dexcom G6 Mis Sensor, transmitter and reader.  You asked the Plan to pre-approve the diabetic supplies. You say that the hospital discharged the enrollee without insulin and had paid out of pocket for the insulin. The Plan denied your request. The Plan says the enrollee only checks sugars 2-3 times per day and is not on injectable insulin. The requested diabetic supplies are not a preferred brand covered under the Plan benefits.     The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The health Plan contract specifically says that test strips and monitors must be obtained from preferred vendors. Test strips and monitors from any other vendor will not be covered. Based on this information, we decided that Medicare rules for coverage of the Dexcom G6 Mis Sensor, transmitter and reader have not been met. Therefore, we decided that the Plan does not have to pre-approve the Dexcom G6 Mis Sensor, transmitter and reader.