Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Aranesp (J0881).
You asked the Plan to pre-approve Aranesp. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Aranesp. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the Plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Aranesp (J0881).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the podiatry visits and the x-rays provided from February 8, 2021, to April 22, 2021.

You asked the Plan to waive the copayments for the podiatry visits and the x-rays. You say that you were told you had 90 days of free postoperative care. 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 $35 copayment for each Medicare-covered podiatry visit and a $10 copayment for each basic imaging service (e.g., general x-rays or ultrasound). 

You have been asked to pay a $35 copayment for the podiatry visit on February 8, 2021 and a $10 copayment for the x-rays on March 25, 2021 and April 22, 2021. The podiatry visits fall within the "Podiatry services" benefit category. The x-rays fall 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 copayments for the podiatry visit and the x-rays provided from February 8, 2021, to April 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an EW-36 E-Lite 3-wheel electric scooter (K0899).
You asked the Plan to pre-approve a 3-wheel electric scooter. You say that the 3-wheel scooter would better help you get around on your own and be independent. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that a POV or PWC which has not been reviewed by PDAC or which has been reviewed by the PDAC and found not to meet the definition of a specific POV/PWC will be denied as not reasonable and necessary. We reviewed the file and available information regarding the requested 3-wheel scooter. It does not appear that the manufacturer of this device has submitted the device to the PDAC contractor for review and code assignment. Since this device has not been assigned a covered code, it must be assigned the non-covered mobility device code, K0899. Although this device may be appropriate for you, Medicare payment cannot be made for this item. Therefore, we decided that the Plan does not have to pre-approve an EW-36 E-Lite 3-wheel electric scooter (K0899).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on July 6, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that the records support medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained as required.
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 file shows the enrollee received a follow-up visit for diabetes. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit provided on July 6, 2020 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a right shoulder arthroplasty and will need inpatient admission after surgery. The Plan denied your request. The Plan says there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is approved for a right shoulder arthroplasty. The record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing services.

You asked the Plan to pre-approve home health skilled nursing services. You say that you need someone to come to your home to do your labwork because you cannot leave the house. The Plan denied your request. The Plan says rules for home health services have not been met.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health skilled nursing services have not been met. Specifically, the case record does not contain medical records to document the need for home health care services. Your provider's office has stated that they are not requesting home health visits for you at this time. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation and report on referred slides prepared elsewhere provided on December 1, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the consultation and report on referred slides prepared elsewhere. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided 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 consultation and report on referred slides prepared elsewhere provided on December 1, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a filling (D2331), a crown (D2740), and a core buildup (D2950) provided from March 23, 2021, through April 5, 2021.
You asked the Plan to pay for a filling, a crown, and a core buildup. You say that you want the Plan to pay for the services. The Plan denied your request. The Plan says the services at issue are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a filling (D2331), a crown (D2740), and a core buildup (D2950) provided from March 23, 2021, through April 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).

You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.

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 insertion of a Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show it is safe and effective.

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 insertion of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral facet injections (64493, 64494).
You asked the Plan to pre-approve bilateral facet injections. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested treatment is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that facet joint interventions are considered medically reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet all of the criteria in the Medicare rules section. 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 bilateral facet injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there has been no documentation of a back exam in any of the clinical notes from
October 2020 through September 10, 2021. There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the enrollee's pain, including but not limited to fracture, tumor, infection, or significant deformity. There is no clinical evidence that the source of the member's pain is predominantly axial in etiology. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bilateral facet injections have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral facet injections (64493, 64494).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing (81406, 81405, 81404, 81403, 81402, 81401, 81400, 81321, 81318, 81314, 81311, 81310, 81299, 81293, 81276, 81275, 81272, 81270, 81235, 81210, 81201, 81121, and 81120) provided on March 25, 2021.

You asked the Plan to pay for Guardant360 testing. You say that this is a Medicare-covered service. The Plan denied your request. The Plan says this is not supported by the records.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that code 81479 is used for Guardant360 testing.

We find that CPT codes 81406, 81405, 81404, 81403, 81402, 81401, 81400, 81321, 81318, 81314, 81311, 81310, 81299, 81293, 81276, 81275, 81272, 81270, 81235, 81210, 81201, 81121, and 81120 are not supported in the medical record. Specifically, these codes were used to report Guardant360 testing, which should be billed with 81479. Based on this information, we decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing (81406, 81405, 81404, 81403, 81402, 81401, 81400, 81321, 81318, 81314, 81311, 81310, 81299, 81293, 81276, 81275, 81272, 81270, 81235, 81210, 81201, 81121, and 81120) provided on March 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transit kit (K0108) for a power wheelchair.
You asked the Plan to pre-approve a transit kit. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for durable medical equipment 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 is for use outside of the home. 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 pre-approve a transit kit (K0108) for a power wheelchair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare does not approve use of hyperbaric oxygen therapy in the clinical setting of pre/post dental extraction following radiation in the absence of osteoradionecrosis.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record does not indicate that the enrollee has radionecrosis. The record indicates that the requested service is to prevent radionecrosis. The elements of the coverage criteria are not satisfied. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), and panoramic x-ray (D0330) provided on April 21, 2021. 
You asked the Plan to pay for the intraoral periapical x-rays and panoramic x-ray. You say that when you enrolled in this Plan the agent advised you that your dentist was in-network and you would be covered. The Plan denied your request. The Plan says these services are not covered. 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), and panoramic x-ray (D0330) provided on April 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve for an inpatient hospital admission.

You asked the Plan to pre-approve for an inpatient hospital admission. You say that the medical records provided support the need for inpatient hospital care. The Plan denied your request. The Plan says the inpatient hospital admission is medically reasonable and necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 for an inpatient hospital admission. Our reviewer says that the documentation does not support that the criteria for an inpatient hospital admission were met in this case. Our physician reviewer found the enrollee had brief hearing loss and an episode of aphasia several weeks prior to presentation. Magnetic resonance imaging (MRI) revealed asymmetric pachymenigeal enhancement. On admission the enrollee was hemodynamically and neurologically stable. A spinal tap was ordered. There was insufficient evidence of an acute condition or state that warranted inpatient services. The documentation did not support the enrollee would require hospital services that would likely cross 2 midnights. Additional workup and monitoring could be completed at a lower 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 an inpatient hospital admission have not been met. Therefore, we decided that the Plan does not have to pre-approve for an inpatient hospital admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) and supplies for the enrollee.
You asked the Plan to pre-approve a CGM and supplies. You say that the enrollee is comfortable using this device. The Plan denied your request. The Plan says that the enrollee does not meet prior authorization criteria.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 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 assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) and supplies for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care services coded 99223 provided on February 23, 2021.
You asked the Plan to pay for the initial hospital care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 99223 is initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and 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 problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. We find that CPT code 99223 is not supported in the medical record. Specifically, the documentation supports a detailed examination of low complexity. This means that the records do not support the level of complexity to bill code 99223. Based on this information, we decided that Medicare rules for coverage of the initial hospital care services have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care services coded 99223 provided on February 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 13, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that you were unable to get the authorization before the service was done. The Plan denied your request. The Plan says prior authorization was not obtained as required.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the lab services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the lab services provided on April 13, 2021 by an out-of-network (OON) provider.