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

We decided that the Plan does not have to pay for pneumatic compression device (E0675) pressure pneumatic appliance (E0673) provided February 24, 2021.
You asked the Plan to pay for the pneumatic compression device and appliance. You say that the medical necessity for these services is decided by the physician at the time of surgery at which time the order is completed making requesting an authorization prior to the service impossible. The Plan denied your request. The Plan says a pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
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 find that CPT code is not supported in the medical record. Specifically, the enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Based on this information, we decided that Medicare rules for coverage of the pneumatic compression device and appliance have not been met. Therefore, we decided that the Plan does not have to pay for pneumatic compression device (E0675) pressure pneumatic appliance (E0673) provided February 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Gamunex-C (J1561).
You asked the Plan to pre-approve Gamunex-C. You say that the requested drug is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met because the use of the requested drug is an off-label and not medically accepted use.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Gamunex-C. Our reviewer says that the requested treatment is not medically necessary. Our physician reviewer found that the record indicates that requested drug is being used to treat small fiber sensory neuropathy and polyneuropathy. The FDA has not stated that this is an indication for the requested drug. The Medicare drug compendia do not contain a supporting citation for the use of the requested drug for this indication. The elements of the coverage rule are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gamunex-C have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Gamunex-C (J1561).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee's condition. 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 daily skilled services are not necessary. Our physician reviewer found that at the time of discharge from the hospital the member had stabilized medically. The member did not require any skilled nursing or rehab services on a daily basis at an inpatient level of care. She was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration. The member did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care at the time of discharge from the hospital. The member did not have any parental medication, complex wound care or nutrition given via a feeding tube. She was medically stable without any acute exacerbations of chronic medical problems. Her physical function was at or near her baseline and she could have received further services at a lower level of care Admission to the nursing facility at a skilled level of care for inpatient skilled services was 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the OrCam My Eye 2.0 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 this is a low vision aid which is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear.
The services you asked the Plan to pre-approve are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pre-approve the OrCam My Eye 2.0 device.
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 radiculopathy. The requested Vertiflex device is indicated for patients with impaired physical function who experience relief in flexion from symptoms of leg/buttock/groin pain, with or without back pain, who have undergone at least six months of non-operative treatment. The records do not show that the services are medically necessary for the enrollee at this 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not
medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found there is no
documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the
present acute care hospital. The enrollee does not require services at the LTACH that are not available at the
acute care hospital where she is currently receiving care. There are no services available at the LTACH that the
enrollee requires that are not available at the health care setting being offered by the health plan. The requested
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of
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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shoulder arthroscopy with rotator cuff repair.

You asked the Plan to pre-approve a shoulder arthroscopy with rotator cuff repair. You say that the requested shoulder arthroscopy with rotator cuff repair is medically necessary. The Plan denied your request. The Plan says the requested shoulder arthroscopy with rotator cuff repair 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 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 shoulder arthroscopy with rotator cuff repair. Our reviewer says that the requested shoulder arthroscopy with rotator cuff repair is not medically necessary. Our physician reviewer found the medical records do not include the results of appropriate shoulder imaging studies prior to surgery. An MRI or shoulder arthrogram is needed at this time to confirm medical necessity. 

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 shoulder arthroscopy with rotator cuff repair have not been met. Therefore, we decided that the Plan does not have to pre-approve a shoulder arthroscopy with rotator cuff repair.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.

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 admission to a LTACH is not medically necessary. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the placement of a breast localization device (19285)
provided on February 11, 2021.
You asked the Plan to pay for the placement of a breast localization device. You say that this is supported in
the records. The Plan denied your request. The Plan says this was not billed with a required device.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. The submission of a device-dependent
procedure also requires that a device be submitted on the same claim/day.
In this case, the CPT Code Manual definition of code 19285 is placement of breast localization device(s) (e.g.,
clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including ultrasound guidance.
We find that CPT code 19285 is not supported in the medical record. Specifically, this is a device-depended
procedure that was not reported with a device submitted on the same claim. Based on this information, we
decided that Medicare rules for coverage of the placement of a breast localization device have not been met.
Therefore, we decided that the Plan does not have to pay for the placement of a breast localization device
(19285) provided on February 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care for the enrollee.

You asked the Plan to pre-approve inpatient mental health care. You say that inpatient mental health care is
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment. 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 inpatient
mental health care. Our reviewer says that Medicare coverage criteria are not met.

Our physician reviewer found this 72-year-old female was admitted to the acute inpatient psychiatric
hospitalization on July 1, 2021. Based upon review the records provided it is not expected this enrollee would
improve in a reasonable period of time as she did not have dangerousness to self or others and was not showing
any auditory/visual hallucinations or any aggressive behaviors. It does not appear medically necessary and
reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care.
The Plan's denial of inpatient psychiatric services appears appropriate. There is no individualized treatment
plan provided. Medicare criteria for inpatient mental health treatment were not met. We looked at this
physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have
to pre-approve inpatient mental health care for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on February 26, 2021.

You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the charges because a Plan representative told you that you should not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.

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 $110 copayment for ultrasounds. 

You have been asked to pay a $110 copayment for an ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. 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 an ultrasound provided on February 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the reduction of osseous tuberosity (D7485) received December 17, 2020.
You asked the Plan to pay for the reduction of osseous tuberosity. You say that the requested service was necessary. The Plan denied your request. The Plan says the requested service is not covered under your supplemental benefit.
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 pay for the reduction of osseous tuberosity (D7485) received December 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99213) provided on January 18, 2021.

You asked the Plan to waive the copayment for an office visit. You say that you thought you would not have a copayment for this service. The Plan denied your request. The Plan says the correct copayment was applied.

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 $45 copayment for vision services. 

You have been asked to pay a $45 copayment for an office visit. The service at issue falls within the vision services benefit category. 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 an office visit (99213) provided on January 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings (D0274) provided on February 19, 2021.
You asked the Plan to pay for the bitewings. You say that you changed health plans this year, and have the right to two x-rays. The Plan denied your request. The Plan says this service is allowed two times per calendar year. The Plan also says that you have reached this limit for this 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, bitewing x-rays and intraoral x-rays are limited two of either codes D0220, D0230, D0270, D0272, D0273, or D0274 per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) and an additional intraoral periapical x-ray (D0230) on February 19, 2021 and your bitewing x-rays and intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewings (D0274) provided on February 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve colorectal screening.
You asked the Plan to pre-approve oncology (colorectal) screening (81528). You say that the enrollee needs
this test. The Plan denied your request. The Plan says the enrollee does not have any symptoms and is not
between 50-85 years of age.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal, oncology (colorectal) screening (81528), is being requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to pre-approve colorectal screening.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services with dental codes D7530, D9239, and D9243.

You asked the Plan to pre-approve dental codes D7530, D9239, and D9243. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says dental code D7530 is not covered under the Plan's supplemental dental benefit, therefore, D9239, and D9243 are not covered under the Plan's supplemental dental benefit.

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 dental services with dental codes D7530, D9239, and D9243.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of home health skilled care services.

You asked the Plan to pre-approve the continuation of home health skilled care services. You say that these services continue to be medically necessary. The Plan denied your request. The Plan says your needs no longer appear to be skilled in nature.

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 continuation of home health skilled care services. Our reviewer says that the requested home health skilled care services are no longer medically reasonable and necessary. Our physician reviewer found in this case, the documentation does not support that you continue to require in-home skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The documentation does not support that the member is homebound. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The requested home health services are not medically necessary as the member can receive services on an outpatient basis. 

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 continuation of home health skilled care services have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of home health skilled care services.
Sincerely,