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

We decided that the Plan does not have to pre-approve a removable unilateral partial denture (D5281).You asked the Plan to pre-approvethe removable unilateral partial denture. You say that you need the denture for your upper right quadrant so you can chew your food.The Plan denied your request. The Plan says this service is not a covered 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-approvea removable unilateral partial denture (D5281).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0642) provided to the enrollee on September 5, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the proof of delivery is invalid and cannot be verified.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 shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery or physician order for the supplies provided in this case. The itemized shipping/billed invoice includes a billed code that does not reflect the billed codein the appeal. The code cannot be verified.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0642) provided to the enrollee on September 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee is not clinically appropriate for a lower level of care, as evidence by his current chronically critical ill status. You say that the continuity of care offered at the LTACH is the best opportunity for continued improvement and eventual discharge home.The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met.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 does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. All medically necessary are is being provided in the current acute care setting. 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 health plan has approved ongoing care in the current acute care 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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on February 11, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on February 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora hip brace with abduction orthosis (L1686, L2624) provided to the enrollee on September 10, 2019.You asked the Plan to pay forthe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora hip brace with abduction orthosis (L1686, L2624) provided to the enrollee on September 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plan denied your request. The Plansaysthe enrollee is receiving appropriate inpatient acute care, and does not require transfer to the LTACH.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate forthe 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 is currently undergoing treatment at an ACH for pneumonia following recent coronary bypass surgery. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-termcare 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 the LTACH services have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a long-term acute care hospital (LTACH) for the enrollee
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on May 2, 2019.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on May 2, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that this will help with swelling in your arm. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered 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 stockings identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that you would like the items because they've helped you in the past. The Plan denied your request. The Plan says the compression stockings are noncovered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered 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 stockings identified with code A6530.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3mg Vraylar capsules.You asked the Plan to pre-approve the Vraylar. You say that the member has been stable on this dose of medication since February 10, 2017. The Plan denied your request. The Plan says the Vraylar capsules are to be obtained via the pharmacy benefit and are not Medicare covered under the Part A or B benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve 3mg Vraylar capsules. Benefits for the Vraylar may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat upper endoscopy for the enrollee.You asked the Plan to pre-approve the endoscopy. You say that this is medically necessary.The Plan denied your request. The Plan says the documentation received fails to indicate that the enrollee has an approved diagnosis.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 endoscopy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the available record does not support per CMS coverage rules that medically necessary circumstances exist to warrant the second EGD as requested above "to perform a dilatation to hopefully improve his swallowing function and alleviate the aspiration issues." Modified barium swallow on 12/16/2019 described "some aspiration of barium" per provider comments but no stenosis. Stenosis was also not described at the time of initial EGD on 2/21/2020 -a study that was complete to the descending duodenum and performed per gastroenterology protocol. No motility studies however have since been performed, and the necessity of "dilatation" by second EGD as proposed is not apparent from available records. Indeed, the "esophagus was deemed patulous with air-fluid level" suggesting that dilation may offer questionable real benefit here.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission and services for enrollee.You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does not need daily skilled services on an inpatient basis in a SNF.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 services. Our physician reviewer found that from a nursing perspective, the enrollee has stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at a maximal assist level of bed mobility and transfers. The enrollee requires varying assist with activities of daily living. There are no identifiable skilled therapy service needs. The enrollee does not require skilled services on a daily basis. The enrollee does not meet  severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services for enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the removal of the LINQ heart monitor (33286). You say that your monitor needs to be changed as it is painful and poking out of the skin. The Plan denied your request. The Plan says this service is available within your health plan network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be providedby an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve teeth extractions (D7210).
You asked the Plan to pre-approve teeth extractions. You say that this is necessary for the enrollee's health. The Plan denied your request. The Plan says these dental services are not covered by Medicare or the Plan.
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 teeth extractions (D7210).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power tilt-in-space seating option (E1002).You asked the Plan to pre-approve the power tilt-in-space seating option. You say that this service/item is medically necessary.The Plan denied your request. The Plan says medical necessity criteria have not been met.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the power tilt-in-space seating option. Our reviewer says that Medicare coverage guidelines are not met. Our physician reviewer found the document does not support the enrollee is unable to independently transfer from the wheelchair to the bed nor is the requested system noted to manage increased tone or spasticity. Without the support of the documentation, medical necessity cannot be determined. The denial is upheld.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 power tilt-in-space seating option have not been met.Therefore, we decided that the Plan does not have to pre-approvea power tilt-in-space seating option (E1002).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) and  shoulder-hand-wrist orthoses with (L3960, L3961) provided to the enrollee on March 6, 2019.You asked the Plan to pay for the orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the physician order was invalid.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. The newly submitted physician order shows that the supplies were prescribed via telehealth. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay foran ankle-foot orthosis (L1971) and  shoulder-hand-wrist orthoses with (L3960, L3961) provided to the enrollee on March 6, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approvePrivigen 80 grams every 21 days for the enrollee.You asked the Plan to pre-approvethese services. You say that the higher IgG trough levels have resulted in less frequent pneumonia and sepsis.The Plan denied your request. The Plan says that that this is not medically necessary or appropriate.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 these services. Our reviewer says that Privigen 80 grams every 21 days is medically reasonable and necessary for the enrollee in this case. Based on clinical trials and clinical practice amongst immunologists, the target dose of IVIG for a given patient is the dose that protects that individual from significant infections. It has been determined that the dose that leads to an IgG trough level above 1300 mg/dL for this enrollee would bestprotect him from recurrent pneumonia, sepsis and hospitalization. He has a significant history of such serious illnesses. Even if he develops an infection while on the higher immunoglobulin doses, it does not demonstrate that it is not necessary. In fact,it would favor the higher dose given that a lower dose would almost definitely lead to a higher frequency of such infections. Our physician reviewer found that the enrollee's condition meets criteria for coverage of Privigen 80 grams every 21 days.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 been met.Therefore, we decided that the Plan has to pre-approvePrivigen 80 grams every 21 days for the enrollee.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for anti-reflective coating on your covered eyeglasses provided on September 30, 2019.You asked the Plan to adjust the copayment and pay foranti-reflective coating (V2750). You say that the Plan should pay this claim.The Plan denied your request. The Plan says eyeglass upgrades are not covered.The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The serviceyou asked the Plan to pay for isconsidered an eyewearupgrade.Therefore, we decided that the Plan does not have to pay foranti-reflective coating on your covered eyeglasses provided on September 30, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora wrist-hand orthosis (L3916) provided to the enrollee on May 22, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not support thebilled service.The Plan must follow Medicare rules. Medicare rules say that for coverage criteria to be met, the medical record must support the services billed. A review of the file does not show that the supplies were ordered in conjunction witht the face to face office visit. There is no commensurate note in the medical record on or around that date as to why the brace was being ordered. Consequently, the items/services ordered are noncovered.Therefore, we decided that the Plan does not have topay fora wrist-hand orthosis (L3916) provided to the enrollee on May 22, 2019.