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

 We decided that the Plan does not have to pre-approve Udenyca.  You asked the Plan to pre-approve Udenyca. You say that this is medically necessary. The Plan denied your request. The Plan says this use of the drug is not supported.  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 Udenyca. Our reviewer says that the requested use of Udenyca is not supported. Our physician reviewer found the record indicates that the enrollee has acute myelogenous leukemia and the requested drug is being prescribed for prophylaxis of febrile neutropenia.  The enrollee has a myeloid malignancy. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Udenyca have not been met. Therefore, we decided that the Plan does not have to pre-approve Udenyca.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the inpatient hospital services provided on December 25, 2020, through December 27, 2020 and billed with a primary diagnosis code of A41.9.  You asked the Plan to pay for the inpatient hospital services billed with a primary diagnosis code of A41.9. You say that you would like reconsideration because the documentation submitted supports the DRG billed. The Plan denied your request. The Plan says that the documentation submitted does not support a primary diagnosis of sepsis.  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 primary diagnosis code A41.9. 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 inpatient hospital services billed with a primary diagnosis code of A41.9. Our reviewer says that the clinical documentation supports a diagnosis of sepsis, unspecified organism, in this case. Our physician reviewer found the enrollee had fever, tachycardia and tachypnea. The enrollee had a source of infection and laboratory studies that supported the diagnosis of sepsis. A SOFA score of 2 with suspected infection further supports the diagnosis.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for the inpatient hospital services provided on December 25, 2020, through December 27, 2020 and billed with a primary diagnosis code of A41.9.    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: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room visit (99285) provided on September 12, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  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 $65 copayment for emergency care services rendered by an in-network provider.   You have been asked to pay a $65 copayment for the emergency care services rendered by an in-network provider. 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 emergency room visit (99285) provided on September 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a domiciliary or rest home visit (99335) provided on June 21, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a domiciliary or rest home visit. You say that this patient was seen per a referral for sore toenails. The Plan denied your request. The Plan says this is a non-contracted provider who performed services to the member without prior authorization from the Plan.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit (99335) provided on June 21, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acupuncture services (97811, 97810) provided August 31, 2020.  You asked the Plan to pay for the acupuncture services. You say that these services were medically necessary. The Plan denied your request. The Plan says acupuncture is only covered for chronic low back pain.  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.  We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the documentation shows that the acupuncture treatment was not for chronic low back pain. Therefore, we decided that the Plan does not have to pay for the acupuncture services (97811, 97810) provided August 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acupuncture services (97810, 97811, 97026) provided on January 5, 2021, through March 20, 2021.  You asked the Plan to pay for the acupuncture services. You say that you would like reconsideration because you were not aware that the Plan does not cover acupuncture services and are unable to afford the treatment. The Plan denied your request. The Plan says acupuncture is not a Medicare covered benefit for your condition.  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.   We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the documentation does not show that your condition is chronic lower back pain. Therefore, we decided that the Plan does not have to pay for the acupuncture services (97810, 97811, 97026) provided on January 5, 2021, through March 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 22, 27, 28, and 29 and surgical extractions (D7210) for tooth #'s 20 and 21.  You asked the Plan to pre-approve the crowns and surgical extractions. The Plan denied your request. The Plan says crown (D2750) is not covered under your benefit plan. The Plan also says that the documentation submitted does not support the surgical extractions (D7210) code requested for tooth #'s 20 and 21.  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. The Plan covers the surgical extractions when the services are medically necessary and reasonable.   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 surgical extractions. Our reviewer says that given the presentation of the teeth in question, the surgical extractions (D7210) for tooth #'s 20 and 21 are not considered medically necessary. Our physician reviewer found in this instance, tooth #20 is intact and has about 50% of the supporting bone remaining. Tooth #21 has damage to the clinical crown in the order of 50%, but also has 50% bone loss which allows for grasping the tooth below the level of the decayed structure. Our reviewer found that given the loss of alveolar bone, it is more probable than not that tooth #21 will be able to be removed without the need for any cutting of the bone. Our physician reviewer also found that tooth #20 would not be expected to need any cutting of the bone as it is intact and has a loss of the supporting bone as well.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns and surgical extractions have not been met. Therefore, we decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 22, 27, 28, and 29 and surgical extractions (D7210) for tooth #'s 20 and 21.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the endodontic therapy (D3330) provided on July 28, 2021.  You asked the Plan to pay for the endodontic therapy. You say that you needed the root canal to prevent cancer from spreading to your jaw. The Plan denied your request. The Plan says medical necessity has not been established for this service, and none of the Plan's criteria have been met.  Medicare generally does not cover dental services. The Plan follows the same rule.  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the endodontic therapy (D3330) provided on July 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the life-protect device (99199), provided on May 6, 2021.  You asked the Plan to pay for the life-protect device. You say that the item is medically necessary. The Plan denied your request. The Plan says Original Medicare only covers durable medical equipment (DME) from DME suppliers that are enrolled in Medicare.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the life-protect device (99199), provided on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494).  You asked the Plan to pre-approve facet joint injections. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for the requested services have not been met.  The Plan must follow Medicare rules. The rules say that a second confirmatory diagnostic facet joint procedure is considered medically reasonable and necessary when the criteria listed in the Medicare rules section have been met.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Specifically, the medical records provided document that the enrollee did not experience a consistent positive response of at least 80% relief of primary (index) pain. Therefore, we decided that the Plan does not have to pre-approve facet joint injections (64493, 64494).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pain management services provided on August 12, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.  The file shows that electrical nerve stimulation was provided. We looked at the file and the rules. It is inappropriate for a patient to visit his/her physician, physical therapist, or an outpatient clinic on a continuing basis for treatment of pain with electrical nerve stimulation. The file shows that vasopneumatic device therapy was provided. We looked at the file and the rules. The records do not indicate the enrollee's condition required the skills and knowledge of a physical or occupational therapist. Furthermore, review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the state where the services were provided.  The file shows that a nutria-pharmaceutical injection was billed with multiple drug codes. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made.  The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have to pay for the pain management services provided on August 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0631) provided on May 26, 2021.  You asked the Plan to pay for a lumbar-sacral orthosis. You say that the item at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.       The item at issue in this appeal has been billed with a place of service (POS) code of 11, indicating the item was used in a physician office where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0631) provided on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a cardiologist office visit provided on April 7, 2021.  You asked the Plan to waive the copayment for the cardiologist office visit. You say that you received inadequate care during your visit to the cardiologist. The Plan denied your request. The Plan says the copayment applied was correct.  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 copayment for each Medicare covered specialist visit.   You have been asked to pay a $20 copayment for cardiologist office visit. The cardiologist office visit falls within the Physician/Practitioner Services, including doctor's office visits benefit category.  This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the cardiologist office visit provided on April 7, 2021.   Your complaint about your experience with this provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on August 31, 2021, by an OON provider.  

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.    

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 31, 2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the toilet rail (E0243), shower chair (E0240), wheelchair (K0003), commode chair (E0163, E0167), and transfer tub rail attachment (E0246).  

You asked the Plan to pay for the toilet rail, shower chair, wheelchair, commode chair, and transfer tub rail attachment. You say that you need these items. The Plan denied your request. The Plan says the service is not covered by Medicare and the services were obtained from a non-Medicare provider.    

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the toilet rail (E0243), shower chair (E0240), wheelchair (K0003), commode chair (E0163, E0167), and transfer tub rail attachment (E0246).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.  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 admission is not medically necessary.  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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee had a fall on December 27, 2021 and went to the emergency room (ER) on December 28, 2021. She had a fracture of the left distal radius that was splintered in the ER. She had a positive Coronavirus test on January 14, 2022 and a repeat test was negative. She has no skilled nursing needs. She may benefit from skilled therapy but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF level of care.  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 a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pre-approve a high intensity focused ultrasound (HIFU) of the prostate for the enrollee.  You asked the Plan to pre-approve the ultrasound. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no clinical evidence to support the medical necessity for HIFU.  The Plan must follow Medicare rules. Medicare rules say that services are covered 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 the ultrasound. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the criteria chosen by the plan do not apply to the primary treatment of prostate cancer, only for recurrence after radiation failure (salvage). High Intensity Focused Ultrasound (HIFU) ablation of the prostate is neither experimental nor investigational. HIFU was FDA approved for prostate gland ablation October 9, 2015.  HIFU of the prostate (CPT 55880) has Medicare coverage as of July 1, 2017. Numerous clinical studies have demonstrated treatment efficacy that is comparable to surgery or radiation but with a much lower risk of side effects such as impotence, incontinence and bowel injury.  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 ultrasound have been met. Therefore, we decided that the Plan has to pre-approve a high intensity focused ultrasound (HIFU) of the prostate for the enrollee.   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.