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

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you are
receiving adequate intensive rehab in the inpatient rehab facility.
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 SNF services. Our physician reviewer
found that from a nursing perspective, you received oral and inhaled medications, had stable vital signs, and
your lungs were clear. There are no identifiable skilled nursing service needs. Regarding rehab services, you
were at a supervision to contact guard assist level for functional mobility. You required varying assist with
activities of daily living. Although there are identifiable skilled therapy service needs, you do not require
skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service
criteria for 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA 1 and BRCA 2 testing.
You asked the Plan to pre-approve BRCA 1 and BRCA 2 testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested testing.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.
Testing of individuals with no personal history of breast, ovarian, fallopian tube, primary peritoneal, pancreatic, or prostate cancer. Such testing is considered screening and is excluded by Medicare. The documentation does not support that you have had a personal history of breast, ovarian, fallopian tube, primary peritoneal, pancreatic, or prostate cancer. The BRCA 1 and BRCA 2 testing at issue in this appeal are being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve BRCA 1 and BRCA 2 testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (D3330) and intraoral x-rays (D0220).

You asked the Plan to pre-approve the endodontic therapy and intraoral x-rays. You say that the services are medically necessary. The Plan denied your request. The Plan says endodontic therapy is not covered and your benefit for intraoral x-rays has been exhausted.

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 endodontic therapy is not listed as a covered benefit. Intraoral x-rays are covered once a year. The record shows you already received intraoral x-rays within the past 12 months. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy (D3330) and intraoral x-rays (D0220).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement procedure (22869).
You asked the Plan to pre-approve the interspinous spacer. You say that the procedure is medically necessary.
The Plan denied your request. The Plan says coverage criteria has not been met.
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 interspinous spacer. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Vertiflex spacer device is experimental. More research is needed to show safety
and efficacy of the device.
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 interspinous spacer have not been met. Therefore, we decided that the Plan
does not have to pre-approve an interspinous spacer placement procedure (22869).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 speech therapy visits (92523).

You asked the Plan to pre-approve the additional speech therapy visits. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that the amount, frequency, and duration of the services must be reasonable under accepted standards of practice. 

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 additional speech therapy visits. Our reviewer says that the 12 requested speech therapy visits are not medically necessary. Our physician reviewer found the two visits approved by the plan should meet the enrollee's needs. The enrollee resides in a long-term care facility and has caregivers that can reinforce provided skilled treatments. The requested 12 visits exceed the enrollee's needs and are not medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional speech therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 speech therapy visits (92523).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex stabilization device at L4-5.

You asked the Plan to pre-approve the Vertiflex device. You say that you hope for a favorable outcome to approve this request and provide the necessary coverage that your patient should be entitled to, based on enrollment with this Plan. The Plan denied your request. The Plan says there is not enough research to determine that the Vertiflex Superion indirect decompression system improves overall health outcomes when used as a treatment for people with lumbar spinal stenosis.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex stabilization device at L4-5.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an open MRI to be provided by the out-of-network provider.
You asked the Plan to pre-approve the open MRI to be provided by the out-of-network provider. You say that you have restless leg syndrome, and you have severe claustrophobia and you need a stand-up MRI. The Plan denied your request. The Plan says you must receive your care from a network provider. In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be covered. Your group has an in-network MRI center that has open MRI.
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 open MRI. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an open MRI to be provided the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle-foot orthosis (AFO) and lumbar-sacral orthosis (LSO) rendered on April 14, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that an AFO and LSO are covered when specific criteria are met. 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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the documentation does not support that the ankle/foot orthosis was medically reasonable and necessary for the enrollee. A physical examination of the ankles and feet would reasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the ankle/foot orthosis was medically reasonable and necessary in this case, as there is no documentation of a physical examination of the ankles and feet. The enrollee's chief complaint on March 3, 2020 was chronic use of pain medications and right hip pain. The physical exam documented left muscle spasm of the lumbar spine and pain with motion. There is no documentation to support that the LSO was reasonable and medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the ankle-foot orthosis (AFO) and lumbar-sacral orthosis (LSO) rendered on April 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.
You asked the Plan to pre-approve the physician's services. You say that this physician is known for his facial reconstruction and he has authored and co-authored many books and is the doctor to go to for your medical condition. The Plan denied your request. The Plan says while you are a member of our Plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which our plan authorizes use of out-of-network providers. The plan has confirmed there is no network deficiency for the enrollee's service area for the requested service.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp.
You asked the Plan to pre-approve a wheelchair ramp. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare criteria for wheelchair accessories do not cover ramps because they are not for a medical need.
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 a wheelchair ramp.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ellman radiofrequency conjunctivoplasty to be provided by an OON provider.
You asked the Plan to pre-approve radiofrequency conjunctivoplasty. You say that your in-network physician was unable to locate a Plan physician with the equipment for the requested procedure. The Plan denied your request. The Plan says rules for pre-approval have not been met because the requested services can be obtained from in-network providers.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve Ellman radiofrequency conjunctivoplasty to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Lite glucometer.

You asked the Plan to pre-approve the Freestyle Lite glucometer. You say that the Freestyle Lite glucometer is medically necessary. The Plan denied your request. The Plan says Accu-Chek brand glucometers are the preferred brand.

The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers. 

We looked at the file and Medicare rules. The record includes no clinical documentation to show that the plan preferred brand would be unsafe or ineffective for the enrollee. Based on this information, we decided that Medicare rules for coverage of the Freestyle Lite glucometer have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Lite glucometer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression device and garments provided on September 23, 2020.
You asked the Plan to pay for intermittent limb compression device (E0651) and garments (E0667). You say that the device was medically necessary. The Plan denied your request. The Plan says this was a non-covered service.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. 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 intermittent limb compression device (E0651) and garments (E0667). Our reviewer says that the device was not medically necessary. Our physician reviewer found the only time that a segmented, calibrated gradient pneumatic compression device would be covered is when the individual has unique characteristics that prevent them from receiving satisfactory pneumatic compression treatment using a non-segmented device. There is no specific clinical rationale for the requested items. The review has determined that the pneumatic compressor and garments was not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intermittent limb compression device (E0651) and garments (E0667) have not been met. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device and garments provided on September 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic care (98941).

You asked the Plan to pre-approve the chiropractic care. You say that the chiropractic service was medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

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 chiropractic care Our reviewer says that the requested service is not medically necessary. Our physician reviewer found insufficient documentation has been provided to show subluxation of the spine. There were no imaging results provided to show subluxation. 

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 chiropractic care have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic care (98941).
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 the enrollee requires vent weaning, dialysis, chest tube management, and daily physician visits. The Plan denied your request. The Plan says the enrollee can receive the same services at the current level of care.
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 physician reviewer found that the enrollee was admitted to the acute care hospital for chest pain and an aortic dissection requiring repair. The enrollee's hospitalization has been complicated by acute respiratory failure requiring prolonged mechanical ventilation. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Therefore, the requested LTACH services are not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve a CGM. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device.

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.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary to avoid surgery. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation and set-up of a portable x-ray (Q0092 R0070) provided on October 29, 2020.
You asked the Plan to pay for the transportation and set-up of a portable x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the transportation and set up costs are subject to consolidated billing and are not separately billable to Medicare Part B.
The Plan must follow Medicare rules. Medicare rules say that if the patient is in a Part A SNF stay, the transportation and set up costs are subject to consolidated billing and not separately billable to Medicare Part B. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transportation and set-up of a portable x-ray have not been met. Specifically, this claim was billed with place of service code 31 indicating that the member was in a Part A covered SNF stay. When the member is in a Part A covered stay, the transportation and set-up costs are not separately billable to Medicare Part B. Therefore, we decided that the Plan does not have to pay for the transportation and set-up of a portable x-ray (Q0092 R0070) provided on October 29, 2020.