Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve the SNF admission. You say that the enrollee cannot safely return home at
this time. You say that the enrollee's admitting physician, consulting physician, and therapy staff feel that the
enrollee is in need of continued inpatient rehabilitation. The Plan denied your request. The Plan says the
enrollee's current level of function is the same as prior to hospitalization. The Plan also says that there is no
evidence that the enrollee requires skilled services.

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 the SNF admission. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have daily
skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional
nurse. The enrollee did have daily skilled therapy needs that required the specialized skill, knowledge, and
judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled
therapy on an inpatient basis in a SNF setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does
not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 15, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.

The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. 

The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 22, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

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 was 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 pay for the laboratory services rendered on September 22, 202
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a perineural stem cell injection (Q4206).

You asked the Plan to pre-approve the stem cell injection. You say that the injections are medically necessary. The Plan denied your request. The Plan says this treatment is considered experimental and is not 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 stem cell injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the studies reviewed demonstrate some effectiveness with perineural stem cell injections alleviating some of the symptoms of neuropathy. However, the majority of the studies advise that further testing needs to be done in order to confirm these results. These types of amniotic stem cell injections are not considered standard of care at this point. 

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 stem cell injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a perineural stem cell injection (Q4206).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional therapy visits (97164).

You asked the Plan to pre-approve the additional therapy visits. You say that the additional therapy is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that physical therapy services are covered only when 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 the additional therapy visits. Our reviewer says that the additional therapy services are not medically necessary.

Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the patient's condition beyond what was approved by the health plan. The patient has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment. 

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 additional therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional therapy visits (97164).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services to be provided by an out of network provider.

You asked the Plan to pre-approve services with an out of network provider. You say that you need to continue to see your dermatologist. The Plan denied your request. The Plan says they will approve one visit to facilitate a smooth transition of care to an in-network provider.

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 services. Therefore, we decided that the Plan does not have to pre-approve services to be provided by an out of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve physical therapy services to be provided by the requested out-of-network provider. You say that there were no in-network healthcare providers who can provide the specialized physical therapy you need. You say you found this provider who has successfully treated your condition and is currently treating you. The Plan denied your request. The Plan says that the information reviewed does not support the need for out-of-network care. Your information does not show that your condition is emergent in nature. Your information does not show that your care cannot be handled by the Plan's network of providers.

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 services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard - soft appliance, full arch (D9945).

You asked the Plan to pre-approve an occlusal guard. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is not covered under your benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an occlusal guard - soft appliance, full arch (D9945).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on January 26, 2021 by a non-participating provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating provider without prior authorization.

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 the physician services provided on January 26, 2021 by a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper partial denture with a flexible base (D5225).

You asked the Plan to pre-approve the upper partial denture with a flexible base. You say that the service is medically necessary. The Plan denied your request. The Plan says this is not a covered 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, 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 an upper partial denture with a flexible base (D5225).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient hospital observation services rendered from January 20, 2021 to January 25, 2021.

You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the coinsurance was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% of the total cost for out-of-network Medicare-covered observation services.

Review of the file shows that you received outpatient hospital observation services from an out-of-network provider from January 20, 2021 to January 25, 2021. You have been asked to pay 50% of the total cost for these services.

These services fall within the out-of-network Medicare-covered observation 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 coinsurance for the outpatient hospital observation services rendered from January 20, 2021 to January 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from October 13, 2020, through October 14, 2020.

You asked the Plan to pay for the inpatient services. You say that the inpatient services were medically necessary. The Plan denied your request. The Plan says the provider failed to obtain prior approval.

The Plan contract says that authorization is required for inpatient hospital care
.
We looked at the file and the Plan's rules. The file shows that authorization was not obtained for the inpatient hospital care. Therefore, we decided that the Plan does not have to pay for inpatient services provided from October 13, 2020, through October 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care debridement (11043, 11044, 11047) provided on February 24, 2021, by an out of network provider.

You asked the Plan to pay for wound care debridement. You say that the services at issue were a medical necessity for the enrollee. 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 wound care debridement (11043, 11044, 11047) provided on February 24, 2021, by an out of network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on December
31, 2020 by an out of network (OON) provider.

You asked the Plan to pay for these services. You say that you were told that yo uwould be covered. The Plan
denied your request. The Plan says the services were rendered by an out-of-network provider without prior
authorization.

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 the outpatient mental health services provided on December 31, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network imaging provider.

You asked the Plan to pre-approve these services. You say that the network provider is further from your home. The Plan denied your request. The Plan says the services are available from network providers.

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. The Plan confirmed they have a network provider located three miles from your residence. 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 a referral to an out-of-network imaging provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image (D0230) provided February 12, 2021.

You asked the Plan to pay for the additional intraoral x-ray. You say that the cost of the x-ray is too high, and you were unhappy with other services provided by the dentist. The Plan denied your request. The Plan says an intraoral x-ray was covered on the same date of service and therefore frequency limits have been met and the second intraoral x-ray is not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one intraoral x-ray per calendar year. 

We looked at the file and Medicare rules. The Plan provided documentation showing that one intraoral x-ray was covered on February 12, 2021. Based on this information, we decided that the Plan's frequency limit for intraoral x-ray has been met. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image (D0230) provided February 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the continuous glucose monitor (CGM) rendered on January 18, 2021.

You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the coinsurance was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of the cost for Medicare-covered equipment and supplies.

Review of the file show that you received a CGM on January 18, 2021. You have been asked to pay 20% of the cost for these services. These services fall within the Medicare-covered equipment 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 coinsurance for the continuous glucose monitor (CGM) rendered on January 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Gel-One injection.

You asked the Plan to pre-approve a Gel-One injection. You say that the requested Gel-One injection is
medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Orthovisc and
Synvisc/Synvisc-One 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 a Gel-One injection. Our reviewer says
that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is with pain
related to osteoarthritis of both knees. She has failed conservative treatment. Coverage for Gel-One injections
has been requested. The health plan denied coverage for the Gel-One as the plan requires a trial of drug(s)
Orthovisc and Synvisc/Synvisc-One before they will approve the requested drug.

Based on the medical records provided the enrollee has not tried and failed the required drug(s). Based on the
medical records provided 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 a Gel-One injection have not been met. Therefore, we decided that the Plan
does not have to pre-approve a Gel-One injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous transluminal angioplasty (PTA) of the left tibial arteries.

You asked the Plan to pre-approve the PTA procedure. You say that the enrollee would benefit from this treatment. The Plan denied your request. The Plan says this procedure is only covered for the treatment of the iliac, femoral, and popliteal arteries.

The Plan follows Medicare rules. Medicare rules say that PTA may be covered to treat atherosclerotic obstructive lesions in the lower extremity arteries when reasonable and necessary for the enrollee's condition. 

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 PTA procedure. Our reviewer says that while PTA of the tibial arteries may be covered, the documentation does not support that this treatment is medically reasonable and necessary at this time. Our physician reviewer found NCD 20.7 does not specifically limit the use of percutaneous transluminal angioplasty to the iliac, femoral, and popliteal arteries. However, the Qualified Independent Contractor (QIC) Physician Reviewer, a vascular surgeon, noted that the enrollee's most recent ankle-brachial index (ABI) was normal, the enrollee had diagnoses of tendonitis and arthritis, and the report of the angiogram does not indicate if the peroneal artery was occluded. The reviewer recommended that these discrepancies be clarified if an appeal on the basis of medical necessity is to be considered. Without more information, the requested intervention is not shown to be 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 PTA procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous transluminal angioplasty (PTA) of the left tibial arteries.