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

We decided that the Plan does not have to pre-approve the MyoCycle Home FES Cycling Therapy System (E1399).
You asked the Plan to pre-approve this item. You say that this item is medically necessary for the enrollee. The Plan denied your request. The Plan says this item is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that coverage of NMES to treat muscle atrophy is limited to the treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, and other non-neurological reasons for disuse atrophy. 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 this item. Our reviewer says that this item is not medically necessary.
Our physician reviewer found that this item is not medically necessary per the Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k) as Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The evidence for the effectiveness of the MyoCycle Home FES Cycling Therapy System (E1399) in people with spinal cord injuries is limited. There is insufficient evidence in the literature that supports that the use of the MyoCycle FES will be effective for this patient's spinal cord condition or in individuals with paralysis from spinal cord injury in long term improvement of muscle strength, vascular blood flow, bone mineral density, reduction of spasticity and atrophy, facilitation of functional motor movement or reduction muscle atrophy in the upper and lower extremities. Furthermore, the Directory Report (2017-reviewed 2019) revealed Hayes evaluated FES for rehabilitation purposed for spinal cord injury patients. In adult complete spinal cord injury patients the low quality evidence suggests long term effectiveness and safety of FES as well as optimal treatment parameters are unknown. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoCycle Home FES Cycling Therapy System (E1399).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya.

You asked the Plan to pre-approve Ilumya. 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 Ilumya. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found in this case, the Plan requires a trial of Inflectra or Remicade, and Stelara before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits provided from November 11, 2020, to December 9, 2020.You asked the Plan to pay for the services provided. You say that the visits should be reevaluated.The Plan denied your request. The Plan says only manual manipulation of the spine to correct subluxation is covered.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. The Plan offers a routine chiropractic benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.The file shows that you received an office visit by a chiropractor on November 11, 2020, December 2, 7, and 9, 2020. Although your plan offers a benefit that exceeds Medicare coverage, the records show that the routine benefit had already been exhausted. Therefore, we decided that the Plan does not have to pay for the office visits provided from November 11, 2020, to December 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on
September 8, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered
service.
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 pay for the testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that cardiac gene variant testing is not currently recommended for further general risk stratification,
especially in the presence of known established, symptomatic cardiovascular disease. This testing would not be
considered medically reasonable or 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 testing have not been met. Therefore, we decided that the Plan does not have
to pay for the cardiovascular risk assessment panel provided on September 8, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two (2) additional home health PT visits.
You asked the Plan to pre-approve two (2) additional home health PT visits. The Plan denied your request. The Plan says additional home health physical therapy visits do not meet 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. 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 two (2) additional home health PT visits. Our reviewer says that additional home health PT visits are not medically necessary or reasonable. Our physician reviewer found that based on the documentation provided, the health Plan's denial should be upheld. You do not have documented skilled therapy needs. As such, ongoing home health PT is not shown to be medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of two (2) additional home health PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve two (2) additional home health PT visits.
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 documentation provided supports the need for LTACH care. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer to an LTACH.

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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted for pneumonia and sepsis. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the diagnostic tests provided on March 16, 2021.
You asked the Plan to waive the deductible for the diagnostic tests. You say that the bill should be checked and evaluated to result in a favorable outcome. The Plan denied your request. The Plan says the deductible applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your combined deductible is $500. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services.
The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests, therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $500 deductible applies to outpatient diagnostic tests provided in an outpatient hospital. This cost sharing is a contractual obligation that had not been met at the time the diagnostic tests was received on March 16, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the diagnostic tests provided on March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for four (4) outpatient hospital visits provided
on May 7, 2020, to August 18, 2020.

You asked the Plan to waive the copayment for outpatient hospital visits. You say that you did not know you
would be charged a facility fee as well as an office visit copayment. The Plan denied your request. The Plan
says the copayment you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325
copayment for outpatient hospital visits. Your contract with the Plan also clearly says that when you visit a
provider, you may be charged an additional fee. This fee reflects a trend in hospitals buying doctors' practices
and adding additional fees to patient bills.

You have been asked to pay a $325 copayment for each outpatient hospital visit. The records show that the billing provider in this case was the hospital. The records also show that you had four outpatient hospital visits. You have been asked to pay a copayment of $133.58 for each visit, which is less than your copayment of $325 per the EOC ($133.58 x 4 visits = $534.32). This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for four (4) outpatient hospital visits provided on May 7, 2020, to August 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup procedures (D2950), guided tissue
regeneration (D4266), second stage implant surgery (D6011), bone replacement grafts (D7953) and two crowns
(D2750).
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to fully cover all
dental services, as these are medically necessary, and you cannot afford them. The Plan denied your request.
The Plan says only two crowns may be covered per calendar year, and they have already approved two crowns
in 2021. The remaining services at issue are not covered by your dental benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit or are requested in a frequency that exceeds what is covered under this
benefit. Therefore, we decided that the Plan does not have to pre-approve core buildup procedures (D2950),
guided tissue regeneration (D4266), second stage implant surgery (D6011), bone replacement grafts (D7953)
and two crowns (D2750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two removable prosthodontic procedures (D5899 x2), consultation (D9310), therapeutic parenteral drugs (D9612), first 15 minutes of intravenous moderate (conscious) sedation/analgesia (D9239), two subsequent 15 minute increments of intravenous moderate (conscious) sedation/analgesia (D9243 x2), and 14 surgical extractions (D7210 x14), or pay more for the maxillary immediate denture (D5130), mandibular immediate denture (D5140), ten simple extractions (D7140 x10), and two surgical extractions (D7210 x2) provided on February 12, 2021.

You asked the Plan to pay for the removable prosthodontic procedures, consultation, therapeutic parenteral drugs, intravenous moderate (conscious) sedation/analgesia, and 14 surgical extractions, and to pay more for the maxillary immediate denture, mandibular immediate denture, simple extractions, and two surgical extractions. You say that you would like more of these services to be covered. The Plan denied your request. The Plan says the removable prosthodontic procedures, consultation, and therapeutic parenteral drugs are not covered benefits under your dental plan. The Plan also says that your annual maximum benefit 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 removable prosthodontic procedures, consultation, and therapeutic parenteral drugs are not among those covered under this benefit. The Plan also offers a $1,500 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit while processing this claim for the February 12, 2021 date of service, and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the two removable prosthodontic procedures (D5899 x2), consultation (D9310), therapeutic parenteral drugs (D9612), first 15 minutes of intravenous moderate (conscious) sedation/analgesia (D9239), two subsequent 15 minute increments of intravenous moderate (conscious) sedation/analgesia (D9243 x2), and 14 surgical extractions (D7210 x14), or pay more for the maxillary immediate denture (D5130), mandibular immediate denture (D5140), ten simple extractions (D7140 x10), and two surgical extractions (D7210 x2) provided on February 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression sleeves identified with code A6549.

You asked the Plan to pre-approve the compression sleeves. You say that your doctor is recommending these sleeves. The Plan denied your request. The Plan says compression sleeves are not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that compression sleeves described by code A6549 are non-covered because they do not meet the statutory definition of a surgical dressing.

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression sleeves identified with code A6549.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on September 9, 2020.
You asked the Plan to pay for the laboratory services. You say that you were not aware of the requirement of obtaining prior authorization. You say that the referring provider deemed the services medically necessary and you are requesting benefits. The Plan denied your request. The Plan says the provider is not contracted with the Plan and the services were not approved in advance.
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 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 laboratory services provided by an out-of-network provider on September 9, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from September 20,
2019, to October 19, 2019.

You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee required no nursing services which would be considered skilled services by Medicare.

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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on 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 the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from September 20, 2019, to October 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation with an endodontist.You asked the Plan to pre-approve the consultation. You say that you would like this service to be approved for coverage.The Plan denied your request. The Plan says your contract only provides coverage for dental services when they are performed by a participating general dentist. The Plan also says that services performed by an endodontist are not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received by anyone other than a participating general dentist.Therefore, we decided that the Plan does not have to pre-approve a consultation with an endodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the dental services (D0364, D0140, D3310) received March 1, 2021.
You asked the Plan to pay an additional amount for the dental services. You say that you were told this provider was in-network. The Plan denied your request. The Plan says the individual provider at this office is out-of-network. When you receive services from an out-of-network provider, you are responsible for the difference between what is charged by the out-of-network provider and the Plan's maximum allowable charge.
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 payment is in excess of that which is covered under this benefit. Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions. You may be billed by the out-of-network provider for any amount
greater than the payment made by the Plan to the provider. Therefore, we decided that the Plan does not have to pay an additional amount for the dental services (D0364, D0140, D3310) received March 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.

You asked the Plan to pre-approve ten (10) additional PT visits. The Plan denied your request. The Plan says ten (10) additional PT visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 ten (10) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that in this case, you have previously been treated with outpatient therapies and should be independent with a home exercise program. The additional therapy services are not an appropriate duration and frequency for treatment of your medical condition and therefore 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 ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.