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

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that this service is medically necessary. The Plan denied
your request. The Plan says you do not meet criteria for coverage of inpatient skilled nursing facility care.
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 care. Our reviewer says that
inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that you do not
require skilled nursing or skilled therapy services on a daily basis. Additionally, as a practical matter you do
not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility
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 care have not been met. Therefore, we decided that the Plan does not have
to pre-approve inpatient skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99204) provided on February 23, 2021, by an out of network (OON) provider.

You asked the Plan to pay for an office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization.

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. The records provided for review do not show that the services at issue were urgent or emergent. The records provided for review also show that the enrollee was referred by a non-participating provider. 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 an office visit (99204) provided on February 23, 2021, 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 rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. 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. 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 medically necessary. Our physician reviewer found the enrollee was involuntarily
admitted to the hospital on March 16, 2021, with Bipolar type schizoaffective disorder and borderline
intellectual function. Based on the records, it is not expected that he will improve in a reasonable period of
time, as he is not showing dangerousness to self or others and is not having auditory or visual hallucinations.
He is not showing any behavioral issues. It does not appear that active treatment is taking place. Inpatient
treatment is not medically necessary, as he is without perceptual disturbance, agitation, or aggression.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the interspinous decompression device for the enrollee.
You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The
Plan denied your request. The Plan says that experimental and investigational procedures are not covered by
Medicare.
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 requested services are not considered medically reasonable and necessary in this case. The device is
experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer found
that the enrollee's condition does not meet criteria for coverage of these services.
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 the interspinous decompression device for the enrollee.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for continued SNF care.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. We looked at the file and the Medicare rules. The Plan sent additional information to us showing that they made payment for continued SNF services. However, the file does not show that a valid and updated NOMNC was delivered two or more days before the last day of SNF care was approved and paid for. There is no updated last day of coverage for SNF care. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve disposable sensors for use with an interstitial continuous glucose monitor (CGM) (A9276).
You asked the Plan to pre-approve disposable sensors for use with an interstitial CGM. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that codes A9276 (SENSOR; INVASIVE (E.G., SUBCUTANEOUS), DISPOSABLE, FOR USE WITH INTERSTITIAL CONTINUOUS GLUCOSE MONITORING SYSTEM, ONE UNIT = 1 DAY SUPPLY) and A9277 (TRANSMITTER; EXTERNAL, FOR USE WITH INTERSTITIAL CONTINUOUS GLUCOSE MONITORING SYSTEM) describe the supplies used with a non-therapeutic CGM. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of disposable sensors for use with an interstitial CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve disposable sensors for use with an interstitial continuous glucose monitor (CGM) (A9276).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377) and a harness for upgrade to expandable controller (E2313).

You asked the Plan to pre-approve an expandable controller and a harness for upgrade to expandable controller. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories are medically necessary and reasonable 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 pre-approve an expandable controller and a harness for upgrade to expandable controller. Our reviewer says that the items are not medically necessary. Our physician reviewer found the documentation does not support that the expandable controller and harness are medically reasonable and necessary for the enrollee in this case, as there is no documented need for the enrollee to control the power options through a joystick.

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 expandable controller and a harness for upgrade to expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) and a harness for upgrade to expandable controller (E2313).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pressure support ventilator.
You asked the Plan to pre-approve a pressure support ventilator. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that ventilators fall under the Frequent and Substantial Servicing (FSS) payment category, and payment policy requirements preclude FSS payment for devices used to deliver continuous and/or intermittent positive airway pressure, regardless of the illness treated by the device. (Social Security Act 1834(a)(3)(A)) We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a pressure support ventilator. Our reviewer says that the item is not medically necessary. Our physician reviewer found products classified as HCPCS code E0466 when used to provide continuous positive airway pressure (CPAP) or bi-level positive airway pressure (PAP) (with or without backup rate) therapy, regardless of the underlying medical condition, shall not be paid in the FSS payment category. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a pressure support ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a pressure support ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a limited oral evaluation (D0140), bone replacement graft (D4263), gingival irrigation (D4921), alveoloplasty in conjunction with extractions (D7311), and other drugs (D9630).
You asked the Plan to pre-approve a limited oral evaluation, bone replacement graft, gingival irrigation, alveoloplasty in conjunction with extractions, and other drugs. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 limited oral evaluation (D0140), bone replacement graft (D4263), gingival irrigation (D4921), alveoloplasty in conjunction with extractions (D7311), and other drugs (D9630).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiac catheterization (92924, 92943, 93458, 92928) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve OON cardiac catheterization. You say that this cannot be done near the enrollee's home. The Plan denied your request. The Plan says the requested services are available in-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 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 cardiac
catheterization (92924, 92943, 93458, 92928) to be provided by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea.
You asked the Plan to pre-approve Eylea. You say that the requested Eylea solution is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Mvasi or Zirabev first.
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 Eylea. Our reviewer says that the Plan's
step therapy criteria have not been met. Our physician reviewer found the review has determined that the
request for treatment with a Vascular Endothelial Growth Factor Inhibitors for Ocular Indications has been
approved. The Plan requires a trial of Mvasi or Zirabev first before they will approve the requested drug. In this
case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating
that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Eylea have not been met. Please note, due to an issue with the supplier, there is
currently a shortage of packaged Avastin for intravitreal injection. As a result of this shortage, CMS has issued
that Plans cannot impose certain step therapy rules for Avastin. However, in this case, the Plan's step therapy
criteria include two other drugs the enrollee must try and fail first. Therefore, we decided that the Plan does not
have to pre-approve Eylea.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five (5) additional home health PT visits.

You asked the Plan to pre-approve five (5) additional home health PT visits. You say that five (5) additional home health PT visits is medically necessary. The Plan denied your request. The Plan says five (5) additional home health PT visits does not meet Medicare medical necessity criteria.

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.

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 five (5) additional home health PT visits. Our reviewer says that the additional home health PT visits are not medically necessary. Our physician reviewer found that based on the medical records provided there is no documentation that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. Based on the available records you appear to have improved with therapy to the point of being able to manage basic activities of daily living in your home. Further skilled therapy at this point does not appear to be likely to achieve any significant improvement in your symptoms or functional status.

Further utilization of the home exercise program appears appropriate at this point.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of five (5) additional home health PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve five (5) additional home health PT visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (CPT code G0483-90) provided to the enrollee on November 12, 2020.

You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. CPT code G0483-90 (1 Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.

Also, the laboratory results submitted indicate the specimen was collected on November 12, 2020, and received by the lab on November 13, 2020; therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the drug testing (CPT code G0483-90) provided to the enrollee on November 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided on September
23, 2020.
You asked the Plan to pay for a neuromuscular stimulator. You say that this is supported by the records. The
Plan denied your request. The Plan says there is not a proof of delivery for this item.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a valid proof of delivery for the supplies provided in this case. A proof of delivery
was not included in the submitted medical records. The record shows that the Plan made several attempts to
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay
for a neuromuscular stimulator (E0745) provided on September 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on January 28, 2021.
You asked the Plan to pay for the ambulance service. You say that you fell and were having difficulty breathing. You say that emergency medical services were called to your home. You say that they assessed you and advised that transport was not recommended due to the Covid-19 risk in the emergency room. You also say that you believe the services should be covered. The Plan denied your request.
The Plan says non-transport ambulance services are not covered. The Plan says that authorization is required for non-emergency Medicare-covered ambulance ground and air transportation. The Plan also says that there was no authorization on file.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on January 28, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a male vacuum erection system (L7900).
You asked the Plan to pre-approve a male vacuum erection system. You say that this is being requested for a
diagnosis of male erection dysfunction. The Plan denied your request. The Plan says that this is not a covered
benefit.
The Plan must follow Medicare rules. Medicare rules state that vacuum erection devices and related supplies
are not covered because they are statutorily non-covered. Therefore, we decided that the Plan does not have to
pre-approve a male vacuum erection system (L7900).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PureWick urinary collection system to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the urinary collection system. You say that you need this system because your mother's mobility is limited, and you cannot get her out of bed to go to the bathroom as many times as she goes to the bathroom and it is hard to even use a bed pan. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 PureWick urinary collection system to be provided by an out of network (OON) provider.