Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure and surgical extraction provided on December 16, 2020 by a Medicare opt out provider.
You asked the Plan to pay for the preventive procedure and surgical extraction. You say that you were referred to this provider by another participating provider. The Plan denied your request. The Plan says the treating provider has opted out of Medicare effective October 1, 2016, to October 1, 2022.
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 a provider who has opted out of Medicare. Therefore, we decided that the
Plan does not have to pay for the preventive procedure and surgical extraction provided on December 16, 2020 by a Medicare opt out provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy provided on August 3, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for the psychotherapy. You say that the service was provided with no adequate time
frame to obtain authorization for the service. You say the service was medically necessary. The Plan denied
your request. The Plan says no prior authorization was obtained.
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 the psychotherapy provided on August 3, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX (J7321).
You asked the Plan to pre-approve Supartz FX. You say that the enrollee has failed conservative treatment with Apirin, Mobic, as well as Corticosteroid injections. You also say that the enrollee has tried wearing a brace with mild relief. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.
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 Supartz FX. Our reviewer says that
Supartz FX (J7321) is not medically reasonable and necessary for the enrollee. Our physician reviewer found
based on the medical records provided the enrollee has not tried and failed the required drugs, Orthovisc and
Monovisc. Our reviewer also found that there is no indication that the Plan's required drugs 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 Supartz FX have not been met. Therefore, we decided that the Plan does not
have to pre-approve Supartz FX (J7321).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.
You asked the Plan to pre-approve a stair glide. The Plan denied your request. The Plan says the stair lift is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair glide.
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 the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.
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 enrollee does not require treatment by multiple therapies and there are no complex nursing or rehabilitation needs.
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. Specifically, medically necessary services can be provided in a different level of care. This means admission into an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and 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 IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 that the patient was admitted for coronary artery bypass grafting and pacemaker placement. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. In conclusion, there is not a reasonable expectation that this patient 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: 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 the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary or reasonable.
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 patient does not require treatment by multiple therapies and there is no complex nursing or rehabilitation needs.
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. Specifically, medically necessary services are available at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal maintenance.
You asked the Plan to pre-approve the periodontal maintenance. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is not a covered benefit until after minimum of 3 months after periodontal scaling and root planing. The Plan also says that you have been approved for periodontal scalings and root planings.
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, periodontal maintenance cannot be done until after the preliminary procedure is completed. As this was requested at the same time as the periodontal scalings and root planings, the periodontal maintenance cannot be approved. Therefore, we decided that the Plan does not have to pre-approve periodontal maintenance.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot prosthetics to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says there are in-network providers available.
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 OON services. Therefore, we decided that the Plan does not have to pre-approve foot prosthetics to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor (CGM) supplies provided on July 23, 2020.
You asked the Plan to pay for the CGM supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the items rendered are not supported by the documentation.
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. Review of the file shows that an itemized shipping/billing invoice to indicate the specific supplies or proof of delivery was not included in the documentation. The submitted invoice indicates that the items were shipped on July 24, 2020; however, the billed date of service is July 23, 2020. 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 the therapeutic continuous glucose monitor (CGM) supplies provided on July 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home ventilator, any type, used with non-invasive interface (E0466) for 9 additional months.
You asked the Plan to pre-approve 9 months use of the ventilator. You say that the enrollee has clearly benefited for several years from this ventilator. The Plan denied your request. The Plan says the requested device is being used in the bilevel PAP mode rather than being used as a home ventilator.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.
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 9 months use of the ventilator. Our reviewer says that the service is not medically necessary. Our physician reviewer found the records provided do not support the medical necessity or reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 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 additional 9 months use of the ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve home ventilator, any type, used with non-invasive interface (E0466) for an additional 9 months.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328).
You asked the Plan to pre-approve Gelsyn-3. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.
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 Gelsyn-3. Our reviewer says that Gelsyn-3 is not medically reasonable and necessary for the enrollee. Our physician reviewer found based on the medical records provided the enrollee has not tried and failed the required drugs, Orthovisc and Monovisc. Our reviewer also found that there is no indication that the Plan's required drugs 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 Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3 (J7328).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray, chest (71045) provided December 14, 2020.
You asked the Plan to pay for the x-ray. You say that the enrollee had multiple exams on this date of service. Attached reports to support level of service. Please reconsider for processing. The Plan denied your request. The Plan says the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Procedure code incidental for the primary procedure.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code the x-ray has a bundled relationship with code 36556 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray, chest (71045) provided December 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for sensors for a therapeutic CGM (K0553) provided on February 26, 2020, by an out of network provider.
You asked the Plan to pay for CGM sensors. You say that the requested items are a medically necessary standard of care for the enrollee's condition. The Plan denied your request. The Plan says rules for out of network care have not been met.
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 sensors for a therapeutic CGM (K0553) provided on February 26, 2020, by an out of network 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 the services are medically necessary. The Plan
denied your request. The Plan says the service is not medically necessary or reasonable.
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 patient does not require treatment by multiple therapies and there are no complex
nursing or rehabilitation needs.
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. Specifically, medically necessary services are available at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is 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 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 surgical repair of a hip fracture after a fall. Medical conditions 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.
The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this 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 acute IRF admission and services.
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 stay is medically necessary. The Plan
denied your request. The Plan says the stay 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 LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee was admitted with respiratory failure and pneumonia due to
complications from achalasia. 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 they are not currently
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not
satisfied. The requested service cannot be recommended.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0648) provided October 23, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this provider is not enrolled or certified with Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0648) provided October 23, 2020.