Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Mobile Cardiac Outpatient Telemetry (MCOT) for the
enrollee.

You asked the Plan to pre-approve Mobile Cardiac Outpatient Telemetry (MCOT). You say that Mobile
Cardiac Outpatient Telemetry (MCOT)is medically necessary. The Plan denied your request. The Plan says
Medicare coverage criteria are not met. The Qualified Independent Contractor (QIC) overturned the Plans denial. The Plan requested a reopen and stated that the QIC did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for Mobile Cardiac
Outpatient Telemetry (MCOT). The QIC Physician Reviewer determined that the enrollee was having
significant cardiac rhythm disturbances. It was determined that MCOT was indicated to do longer monitoring
than can be obtained from a standard Holter Monitor, before deciding whether to pursue permanent pacemaker.
The Plan argues that the enrollee did not meet the criteria for coverage. The enrollee is a 70-year-old woman
with a history of chronic atrial fibrillation, diabetes, pulmonary hypertension, chronic kidney disease, and sleep
apnea. The enrollee was noted to have pauses lasting 3-5.5 seconds. The enrollee reported occasional
lightheadedness. Cardizem was discontinued, and the enrollee was tachycardic.

Our Medical Director has concluded that the Plan is correct in this case. It is not documented that the use of a 24-hour ambulatory ECG is unlikely to capture and record the dysrhythmia, and that other testing or monitoring or recording of telemetry has been unrevealing. Prolonged monitoring is not required in this case to ensure the absence of atrial fibrillation prior to the discontinuation of anticoagulation therapy. The documentation does not support that the coverage criteria for MCOT have been met in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Mobile Cardiac Outpatient Telemetry (MCOT) have not been met. Therefore, we decided that the Plan does not have to pre-approve Mobile Cardiac Outpatient Telemetry (MCOT) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve carotid Vertebrobasilar duplex ultrasound (93880).

You asked the Plan to pre-approve the carotid duplex ultrasound. You say that please reconsider approving this test and notify you on next steps.The Plan denied your request. 

The Plan says Medicare does not cover this test when it is used for screening. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the carotid duplex ultrasound have not been met.Therefore, we decided that the Plan does not have to pre-approve carotid Vertebrobasilar duplex ultrasound (93880).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.

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 services are not medically necessary.

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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has lumbar pain with
bilateral radiculopathy. There are only mild lumbar degenerative changes. The requested Vertiflex Superion
spacer is not indicated 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Vertiflex Superion spacer.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

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 step therapy requirement is not 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has osteoporosis. She has
not tried and failed the Plan's required drug, intravenous (IV) bisphosphonate therapy. The records do not show
that the required drug would be contraindicated or less effective; therefore, Prolia is 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Prolia.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you need rehab to fully recover and go back to how you were before surgery. The Plan denied your request. The Plan says you do not require an intensive team to reach your functional goals.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 IRF care. Our physician reviewer found that you were admitted to the acute care hospital for myocardial infarction and coronary artery bypass grafting. Your medical conditions are stable. There are no complex nursing needs. You do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup (D2950), partial upper denture (D5211) and partial lower denture (D5212).

You asked the Plan to pre-approve the core buildup and dentures. You say that these services are necessary. The Plan denied your request. The Plan says a core buildup is not covered under the enrollee's supplemental dental benefit. Dentures may only be covered once every 5 plan years, and the Plan paid for partial dentures for this enrollee in 2017, which is less than 5 years ago.

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 or are requested in a frequency that exceeds what is allowed by the benefit. Therefore, we decided that the Plan does not have to pre-approve a core buildup (D2950), partial upper denture (D5211) and partial lower denture (D5212).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for hyponatremia and non-operative management of a sternal fracture after a fall. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bilevel positive airway pressure (BiPAP) machine (E0470).
You asked the Plan to pre-approve BiPAP machine. You say that you are on oxygen during the night and need this BiPAP. The Plan denied your request. The Plan says you do not meet the Medicare criteria for a BiPAP for your condition.
The Plan follows Medicare rules. Medicare rules state that BiPAP machines may be covered when certain 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 pre-approve BiPAP machine. Our reviewer says that you do not meet the Medicare criteria for the requested BiPAP device. Our physician reviewer found you have chronic obstructive pulmonary disorder (COPD) on oxygen at night. An arterial blood gas done while you were awake and stable and showed a partial pressure of carbon dioxide (PaCO2) of 48, which is mildly elevated but does not meet the Medicare criteria for BiPAP of 52 or greater. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of BiPAP machine have not been met. Therefore, we decided that the Plan does not have to pre-approve a bilevel positive airway pressure (BiPAP) machine (E0470).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (J7318).

You asked the Plan to pre-approve Durolane. You say that this request is medically necessary. The Plan denied your request. The Plan says step therapy criteria 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 Durolane. Our reviewer says that the requested drug is not medically necessary and reasonable. Our physician reviewer found the enrollee is a 73-year-old female with pain related to osteoarthritis of the left knee. In this case, based on the medical records provided the patient has not tried and failed the required drugs Orthovisc and Monovisc. In addition, there is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the patient.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane (J7318).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tumor treatment field therapy.

You asked the Plan to pre-approve the requested services. You say that the requested service is the most appropriate option for the enrollee at the present time. The Plan denied your request. The Plan says the request is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file, and Medicare rules. The medical records show that the enrollee has recurrent right parietal and occipital GBM. Tumor treatment field therapy will be denied as not reasonable and necessary for the treatment of recurrent GBM. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve tumor treatment field therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213).

You asked the Plan to pre-approve the dental service. You say that you feel you were misinformed by a plan representative. You say that you were advised you had $1,000 a year and that insurance would cover 50% of everything else. You say that you cannot afford to pay $1,300 for this service. The Plan denied your request. The Plan says partial upper denture is not listed as a covered service.

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 pre-approve a partial upper denture (D5213).

Your complaint about being misinformed by a plan representative 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osteogenesis stimulator, electrical, non-invasive, spinal applications (E0748).

You asked the Plan to pre-approve the osteogenesis stimulator. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says the records do not support that the enrollee meets the criteria listed in the LCD.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the osteogenesis stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve osteogenesis stimulator, electrical, non-invasive, spinal applications (E0748).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services (99283) provided October 22, 2020.

You asked the Plan to pay for the emergency room services. You say that the services were medically necessary. The Plan denied your request. The Plan says the CPT code billed shares a column I / column II relationship with another CPT code billed the same date.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99283 has a column I / column II relationship with code 99285 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for emergency room services (99283) provided October 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positioning cushion (E0190).
You asked the Plan to pre-approve a positioning cushion. You say that you are appealing for the item due to due to diagnosis of sacral ulcer. The Plan denied your request. The Plan says this item is not a covered benefit
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 positioning cushion (E0190).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve occupational therapy to be provided by an out of network provider.

You asked the Plan to pre-approve occupational therapy with an out of network provider. You say that you need therapy right away and cannot get a referral.The Plan denied your request. The Plan says there are in-network providers that can provide these services.

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 occupational therapy to be provided by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a third cleaning (D1110).

You asked the Plan to pre-approve the dental service. You say that you were not happy with your 2 previous cleanings that you received this year.The Plan denied your request. The Plan says 2 cleanings are covered per year. The Plan also says that the frequency limit has been reached.

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 and cleanings are listed as covered, the frequency limit has been reached. The record shows that the Plan paid for cleanings that you received on February 5, 2021, and April 12, 2021.Therefore, we decided that the Plan does not have to pre-approve a third cleaning(D1110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous passive motion device.

You asked the Plan to pre-approve the device. You say that this is a vital part of your recovery. The Plan denied your request. The Plan says this is being requested for use with the shoulder.

The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery. 

You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-approve a continuous passive motion device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.

You asked the Plan to pre-approve the admission. You say that this is medically necessary.The Plan denied your request. The Plan says there is no significant rehabilitative potential from the current baseline.

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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically, and is ready for discharge from the hospital. There is no requirement for skilled nursing and/or skilled therapy services on a daily basis. Further services can be received at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. There is no parental medication; complex wound care or nutrition given via a feeding tube. Her physical function is at or near her baseline and she can receive services 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 the admission have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for a power wheelchair.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says the services can be provided in the network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a referral out-of-network for a power wheelchair.