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

We decided that the Plan does not have to pay for a domiciliary or rest home visit (99335) provided by an out of network (OON) provider.

You asked the Plan to pay for an OON domiciliary or rest home visit. You say that this was a medically necessary service provided in good faith. The Plan denied your request. The Plan says this was not authorized.

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 a domiciliary or rest home visit (99335) provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a WATTS 3D biopsy (88104).

You asked the Plan to pay for a WATTS 3D biopsy. You say that this is an established standard of practice. The Plan denied your request. The Plan says this is experimental.

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 a WATTS 3D biopsy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the submitted medical records do not include the enrollee's past histology or esophagogastroduodenoscopy results. While the records do describe endoscopic suspicion of short segment Barrett's changes, they do not support the high likelihood of Barrett's esophagus based on presented analysis of submitted esophageal tissue. As such, the service at issue is 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 a WATTS 3D biopsy have not been met. Therefore, we decided that the Plan does not have to pay for a WATTS 3D biopsy (88104).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740).

You asked the Plan to pay for the crown. You say that you did not realize these services would exceed your benefit's maximum allowance and you cannot afford them. The Plan denied your request. The Plan says prior to the date of service in question, the Plan had already paid $564 for dental services covered by your benefit. The total allowed amount for the crown was $1,348. The Plan paid the remaining amount of your annual $1,200 annual maximum and you are left to pay the remainder of the cost for this service per your benefit contract.

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, benefits provided in excess of the $1,200 annual maximum are not covered. The Plan provided documentation to show that they have paid the full amount allowed by the benefit. Therefore, we decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share amount for the prophylaxis (D1110) and the
complete series x-ray (D0210).

You asked the Plan to waive the cost share amount for the dental services. You say that you were diagnosed
with an infection. You say that the services you received were medically necessary. You also say that the
services should be covered. The Plan denied your request. The Plan says complete series x-ray is listed as a
Class 2 Basic Service. The Plan says that Class 2 Basic Services have a 50% coinsurance. The Plan also says
that there is a $0 copayment for prophylaxis.

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 and complete series x-ray is listed as a
covered service, there is a 50% coinsurance for this service. The Evidence of Coverage clearly states that you
pay a 50% coinsurance for Class 2 Basic Services, including complete series x-ray. Additionally, the record
shows that you do not owe anything for the prophylaxis. Therefore, we decided that the Plan does not have to
waive the cost share amount for the prophylaxis (D1110) and the complete series x-ray (D0210).
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 these services are medically necessary. The Plan
denied your request. The Plan says that your ongoing skilled therapy and nursing needs 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. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational
therapy services but based on the medical records provided you do not require an intensive inpatient
rehabilitation therapy program. There is no documentation that you require the intensive rehabilitation therapy
program provided in an inpatient rehabilitation facility. Our physician reviewer found that your condition does
not meet Medicare criteria for IRF care.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided between March 5, 2020 and November 24, 2020.

You asked the Plan to pay for the dental services. You say that you expected a reimbursement for the full allowed amount for covered services. The Plan denied your request. The Plan says dental services are not covered beyond the maximum annual allowance of $525. Prior to the date of service, the Plan paid for dental services in the amount of $109. Therefore, you were correctly reimbursed $416 ($525 - $109 = $416) for the dates of service in question.

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, payment for services in excess of the maximum $525 allowance are not among those covered under this benefit. The Plan provided documentation showing that you were paid for a previous claim in the same year, and the total amount the Plan paid for your dental services was the full $525 maximum. Therefore, we decided that the Plan does not have to pay for the dental services provided between March 5, 2020 and November 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a shingles immunization (90750).

You asked the Plan to pay for the shingles immunization. You say that the vaccine should be covered. The Plan denied your request. The Plan says this immunization is not covered under the Part B medical benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles immunization. The Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to the shingles immunization. Therefore, we decided that the Plan does not have to pay for a shingles immunization (90750).

Benefits for the shingles immunization 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (60699, 77013, 76940).

You asked the Plan to pre-approve the radiofrequency ablation procedure. You say that the services are medically necessary. The Plan denied your request. The Plan says the requested services are investigational and non-covered.

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 radiofrequency ablation procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no guidelines that establish radiofrequency ablation as a standard of care in the United States. The procedure is still considered experimental and investigational.

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 radiofrequency ablation procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (60699, 77013, 76940).
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs 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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a hip fracture after a fall. The enrollee's medical problems 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. 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 this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.

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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a static progressive stretch knee device (E1811).

You asked the Plan to pay for a static progressive stretch knee device. You say that this item was medically necessary for the enrollee. The Plan denied your request. The Plan says this device is not covered when used other than directly after knee joint replacement surgery.

The Plan must follow Medicare rules. Medicare rules say that a continuous passive motion device is only covered when used after a total knee replacement.

We looked at the file and Medicare rules. The file indicates the enrollee did not undergo a total knee replacement. Based on this information, we decided that Medicare rules for coverage of a static progressive stretch knee device have not been met. Therefore, we decided that the Plan does not have to pay for a static progressive stretch knee device (E1811).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.

You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that admission symptoms have stabilized.

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 psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is not expected you would improve in a reasonable period of time as you are not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient psychiatric hospital services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing and home health aide (HHA) visits.

You asked the Plan to pre-approve the requested home health services. You say that it is felt these services are medically necessary to help with daily activities. The Plan denied your request. The Plan says the requested services are not medically necessary.

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 requested home health services. Our reviewer says that the requested home health services are not shown to be medically reasonable and necessary in this case. Our physician reviewer found in order to require Home health care skilled services, the member must be confined to the home, under the care of a physician, and receiving services under a plan of care established and periodically reviewed by a physician. Additionally, the member must be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology; or have a continuing need for occupational therapy. Being homebound means leaving home is a major effort.

In this case, the documentation does not support that the member requires skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The member does not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. 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.

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 requested home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing and home health aide (HHA) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment provided by an out of network (OON) provider.

You asked the Plan to pay for durable medical equipment. You say that you do not feel like it was your responsibility to obtain prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider or the member's primary care physician.

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 durable medical equipment provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a Transthoracic echocardiogram (93306).

You asked the Plan to pre-approve Transthoracic echocardiogram. You say that the service is medically necessary. The Plan denied your request. The Plan says that rules for coverage are not met.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.

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 Transthoracic echocardiogram. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found there is a murmur that is inconsistent with the previous echocardiogram report. An echocardiogram in an enrollee with a previous mitral valve ring repair is medically reasonable and 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 Transthoracic echocardiogram have been met. Therefore, we decided that the Plan has to pre-approve a Transthoracic echocardiogram (93306).

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.

You asked the Plan to pre-approve Durolane. You say that the requested Durolane is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Orthovisc and Monovisc first.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Durolane. Our reviewer says that the enrollee's step therapy criteria have not been met. Our physician reviewer found the enrollee is with pain related to osteoarthritis of both knees, diagnosis confirmed with imaging studies. She has failed conservative treatment including steroid injection and prior Supartz injections; Durolane injections have been requested. The health plan denied coverage for the Durolane as the plan requires a trial of drug(s) Orthovisc and Monovisc before they will approve the requested drug. Based on the medical records provided the enrollee has not tried and failed the required drug(s). There is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane.