Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient telehealth mental health services (90832, 90834, 90836) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the out-of-network mental health telehealth services. You say that you have been using this provider in the past and would like to continue to utilize this provider via telehealth. The Plan denied your request. The Plan says there are network providers available in the local area. The requested provider is not licensed to practice in your state.
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 outpatient telehealth mental health services (90832, 90834, 90836) to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says needed therapy 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. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for confusion and hallucinations after recent spinal surgery. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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 care required by the enrollee exceeds the clinical capabilities of lower levels of care. The Plan denied your request. The Plan says there are not complicated wounds or medications that cannot be given in the current location.
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 acute care for septic shock. In this case, the enrollee has continued wound care requirements being treated with a wound vac. The enrollee continues receiving intravenous antibiotics, electrolyte replacement, and pressors. He is receiving acute care services. Acute care services have not been denied at the current facility. The record does not indicate that there are services the enrollee requires that could only be provided by the LTACH. 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: 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 this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings.
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. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a past medical history of stroke and is living at home receiving home health services. Medical problems 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. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care 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. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says 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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic body pillow.
You asked the Plan to pre-approve a therapeutic body pillow. You say that this was recommended by your provider for your shoulder pain. The Plan denied your request. The Plan says this is not a covered service.
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 therapeutic body pillow.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tolvaptan for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tolvaptan for the enrollee. 

Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 enrolle.

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 are no daily skilled needs.

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 that the enrollee has stabilized medically, and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. 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. 

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 enrolle.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for SNF care have not been met.

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 SNF care is not reasonable and necessary. Our physician reviewer found that the enrollee has a medical history including metastatic uterine cancer and was admitted to the hospital on April 6, 2021, with weakness and failure to thrive. The enrollee has not stabilized medically and does not appear to be ready for discharge from the hospital. There is no documentation to support that the enrollee is stable for discharge to a skilled nursing facility to receive daily rehabilitation therapy. The enrollee continues to require services at an acute hospital. 

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 SNF care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the out-of-network physical therapy services. You say that you would like reconsideration for the denied authorization. The Plan denied your request. The Plan says no medical need has been shown as to why you cannot get physical therapy from a provider in your plan 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 physical therapy services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for definitive drug testing (G0480) provided on December 29, 2020 by an out of network (OON) provider.

You asked the Plan to pay for definitive drug testing. You say that you are a specialized laboratory that performs drug monitoring at the request of the ordering physician who sent you the authorization requisition form. 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 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 definitive drug testing (G0480) provided on December 29, 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 the limited oral evaluation (D0140), the periapical x-ray (D0220), and the extractions (D7140 x 2), the comprehensive oral evaluation (D0150), the complete series x-ray (D0210), and a crown (D2740) provided from September 4, 2020, to October 5, 2020.

You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan denied your request. The Plan says the provider in this case is not a network provider.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Additionally, dental services that you receive out of network are not covered. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), the periapical x-ray (D0220), and the extractions (D7140 x 2), the comprehensive oral evaluation (D0150), the complete series x-ray (D0210), and a crown (D2740) provided from September 4, 2020, to October 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation therapy (36475).

You asked the Plan to pre-approve endovenous ablation therapy. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria for coverage are not met.

The Plan follows Medicare rules. Medicare rules say that invasive procedures for the treatment of varicose veins are considered medically reasonable and necessary when all of the criteria listed in the LCD 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 endovenous ablation therapy. Our reviewer says that the requested ablation therapy is not medically necessary. Our physician reviewer found the criteria for coverage requires the patient's symptoms to be due to the refluxing veins in question, but the patient is morbidly obese with documented severe lymphedema and elephantiasis. It is not possible to attribute her leg symptoms to her vein reflux without documentation of satisfactory arterial perfusion to the lower extremities.

Additionally, the reflux severity is marginal in nondilated veins. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of endovenous ablation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve endovenous ablation therapy (36475).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) testing.

You asked the Plan to pre-approve TTE test. You say that your medications do not seem to be working, and when you go for a stress test you cannot complete it because your throat tightens up. The Plan denied your request. The Plan says the denial of authorization for this test is correct, because a repeat study is not medically necessary for you at this time.

The Plan follows Medicare rules. Medicare rules state that absent acute intervention or a discrete change in clinical signs and symptoms, it is not medically necessary to repeat TTE testing more frequently than annually. 

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 TTE test. Our reviewer says that you do not meet the Medicare criteria for the requested TTE test. Our physician reviewer found you have a longstanding throat pain syndrome that has been evaluated several times with variable responses to treatment, and this was not clearly felt to be angina related. Your previous echocardiogram in June 2020 showed no significant aortic stenosis with even less of an aortic valve pressure gradient than past testing. Your condition appears unchanged, and your last echocardiogram was less than 1 year ago showing no significant aortic stenosis. Based on this, you would not meet the Medicare rules for a repeat echocardiogram in less than 1 year's time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of TTE test have not been met. Therefore, we decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) testing.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health visits.

You asked the Plan to pre-approve the additional home health visits. You say that the additional home health
visits are 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 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 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 home health visits. Our
reviewer says that the additional skilled nursing visits are not medically necessary. Our physician reviewer
found the enrollee does not require additional skilled nursing services to effectively provide treatment or care.
Skilled nursing services are not needed to perform a maintenance program to maintain the enrollee's condition.
The enrollee has been medically stable without any recent exacerbations of chronic medical problems or
hospitalizations.

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 home health visits have not been met. Therefore, we decided that
the Plan does not have to pre-approve additional home health visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 900mcg Belbuca.

You asked the Plan to pre-approve Belbuca. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says this medication does not fall under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve 900mcg Belbuca.

Benefits for Belbuca may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electro-acupuncture device.

You asked the Plan to pre-approve an electro-acupuncture device. You say that this device is medically necessary. The Plan denied your request. The Plan says this is not a covered service based on a lack of medical studies that show this will help your condition.

The Plan must follow Medicare rules. Medicare rules say that any ear or auricular electrical devices are also non-covered by Medicare as electrical acupuncture.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an electro-acupuncture device have not been met. Therefore, we decided that the Plan does not have to pre-approve an electro-acupuncture device.