Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of home health services.
You asked the Plan to pre-approve home health services. You say that you need a lot of help now due to irritable bowel syndrome. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 home health services. Our physician reviewer found the health plan's denial should be upheld. You do not have documented skilled nursing needs. Your care needs appear to be custodial. As such, the requested home health services are not shown to be medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of home health 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 you need help taking care of yourself. The Plan denied your request. The Plan says you do not have complex medical management needs and does not require supervision by rehabilitation physicians.
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 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. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve the SNF admission. You say that SNF care is medically reasonable and necessary. The Plan denied your request. The Plan says SNF care is not medically reasonable and necessary.
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 has stabilized medically
and has been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). The enrollee has
tolerated inpatient rehab services and continues to improve with daily skilled nursing and/or skilled therapy
services. She could benefit from continued services at the current level of care. There is no indication that
transfer to a skilled nursing facility is required. She can continue to receive skilled rehab services at the current
IRF or be stepped down to a lower level of care when appropriate. There are no services offered at a SNF that
are not offered at an inpatient rehab facility.
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 the skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor supplies (K0553) provided to the enrollee on February 22, 2021.
You asked the Plan to pay for the continuous glucose monitor supplies. 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. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use.
The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor supplies (K0553) provided to the enrollee on February 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from March 15, 2021, to April 12, 2021.
You asked the Plan to pay for SNF care. You say that this should be covered by Medicare. The Plan denied your request. The Plan says the enrollee did not have daily skilled needs.
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 pay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found for the dates at issue, the enrollee did not have documented skilled nursing or therapy needs. The enrollee's care needs at this point were custodial and could have been provided at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from March 15, 2021, to April 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Prolia (J0897).
You asked the Plan to pre-approve the tier exception.. You say that the cost tier exception is necessary for the enrollee. The Plan denied your request. The Plan says this drug is not eligible for a tier exception.
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. We looked at the file and Medicare rules. The drug requested, Prolia, is covered under the Part B Medical benefit. Therefore, Prolia is not eligible for a cost tier exception. Based on this information, we decided that Medicare rules for coverage of the tier exception. have not been met. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Prolia (J0897).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve polysomnography (95810).
You asked the Plan to pre-approve polysomnography. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a single polysomnography (PSG) is usually sufficient to titrate pulmonary artery pressure (PAP) therapy.
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 polysomnography. Our reviewer says
that the services are not medically necessary. Our physician reviewer found the clinical information was
reviewed and the requested code 95810 duplicates the diagnostic portion of the approved sleep study with
pressure titration. The review indicates that the enrollee does not meet the coverage criteria.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of polysomnography have not been met. Therefore, we decided that the Plan does
not have to pre-approve polysomnography (95810).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc.
You asked the Plan to pre-approve Orthovisc. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that the patient's medical record should contain documentation that fully supports the medical necessity for intra-articular injections of sodium hyaluronate (Hyalgan, Supartz or Visco-3, Euflexxa, Monovisc, GelSyn-3, GenVisc 850, Durolane, TriVisc, Synojoynt, Triluron), hylan G-F 20 (Synvisc, Synvisc-One ), hyaluronic acid (Gel-One), high molecular weight hyaluronan (Orthovisc) and high molecular weight viscoelastic hyaluronan (Hymovis). 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 Orthovisc. Our reviewer says that the services are not medically necessary.
Our physician reviewer found [the requested use is not supported in the Medicare approved compendia. The literature is insufficient to establish the medical necessity or reasonableness, as defined by Medicare rules, of the requested service in the enrollee's clinical scenario. The requested service is not medically necessary and reasonable as defined by Medicare rules. 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 Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond July 31, 2021.
You asked the Plan to pre-approve the continued SNF care. You say that you are not yet fully recovered and need to remain in the SNF. The Plan denied your request. The Plan says daily skilled services are no longer required.
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 continued SNF care. Our reviewer
says that daily skilled services are not necessary. Our physician reviewer found the member is a 74-year-old
female with a past medical history including hypertension who was admitted to the hospital with an acute
stroke and a fractured right hip. She stabilized and was transferred to an inpatient rehab facility for 27 days
then admitted to a skilled nursing facility on 6/10/21 to complete rehab services.
At the time of admission, the member required skilled rehab services to improve function due to weakness and
deconditioning. There were no skilled nursing needs. As of 8/1/2021 the member did not require any skilled
nursing or rehab services on a daily basis. She was not expected to make measurable gains within a reasonable
and predictable period of time or require skilled therapy to prevent deterioration. The member did not require
skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member did not
require any skilled services on an inpatient basis, at a SNF level of care as of 8/1/2021. Ongoing needs appear
to be custodial in nature.
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 continued SNF care have not been met. Therefore, we decided that the Plan
does not have to pre-approve continued skilled nursing facility (SNF) care beyond July 31, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the intraoral - periapical first radiographic image. We decided that the Plan does not have to pay for the custom fabricated abutment - includes placement (D6057), and the abutment supported porcelain/ceramic crown (D6058) received April 6, 2021.
You asked the Plan to pay for the intraoral - periapical first radiographic image. You say that you had a planned dental procedure in 2020 and were forced to wait until 2021 for the procedure to be completed. The Plan says that there is no coverage for the custom fabricated abutment, or the abutment supported porcelain/ceramic crown under your 2021 benefit, and that the frequency limitation for the intraoral periapical radiographic image has been exhausted.
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.
We decided that the Plan has to pay for the intraoral periapical first radiographic image (D0220) received April 6, 2021.
The Plan contract states that your benefit includes up to two x-ray procedures every calendar year. The Plan denied your request for reimbursement for this service on the basis that the frequency limitation had been exceeded. The Plan submitted evidence that coverage for x-ray procedures was provided by the Plan on December 29, 2020. We find that this denial does not accurately reflect the Plan's 2021 contract coverage language. Specifically, the contract states "dental x-ray(s) (for up to 2 every year)." We find it reasonable to expect that this benefit would reset at the beginning of the calendar year on January 1. No evidence has been submitted which indicates coverage of x-ray procedures was provided earlier in 2021. Based on the available information we find the Plan's denial to be incorrect. Therefore, we decided that the Plan has to pay for the intraoral periapical first radiographic image (D0220) received April 6, 2021.
We also decided that the Plan does not have to pay for the custom fabricated abutment - includes placement (D6057), and the abutment supported porcelain/ceramic crown (D6058) received April 6, 2021.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment - includes placement (D6057), and the abutment supported porcelain/ceramic crown (D6058) received April 6, 2021.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 15, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests 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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on January 15, 2021.
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 an IRF admission is medically necessary. The Plan denied your request. The Plan says an IRF admission is not medically necessary. Your needs could continue to be met in the skilled facility or at home with home health services and caregiver assistance if requested.

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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for portable oxygen and oxygen concentrator provided on March 11, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the oxygen supplies. You say that you were told that this vendor was not doing rentals and you needed the G5 because it has five settings. The Plan denied your request. The Plan says the enrollee self-referred out of network. Therefore, the request is not approved.

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 portable oxygen and oxygen concentrator provided on March 11, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wig (99998).

You asked the Plan to pre-approve a wig. You say that providing a hair prosthesis is standard of care, not out of the ordinary and done for every patient who requests it. The Plan denied your request. The Plan says this is a comfort or convenience item that is not primarily medical in nature and is not covered by Medicare.

Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. 

In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig (99998).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the FreeStyle Libre CGM provided on February 22, 2021.

You asked the Plan to pay for the FreeStyle Libre CGM. You say that you would like reconsideration because the member meets criteria for the CGM. The Plan denied your request. The Plan says that the documentation does not support medical necessity or that the physician discussed the need for these supplies with the member.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered reasonable and necessary for enrollees with diabetes who meet criteria referenced above. 

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 the FreeStyle Libre CGM. Our reviewer says that Medicare criteria for coverage have been met. Our physician reviewer found the member adjusts insulin acording to their blood glucose level 4 times per day and is advised to check 4 times per day. 

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 FreeStyle Libre CGM have been met. Therefore, we decided that the Plan has to pay for the FreeStyle Libre CGM provided on February 22, 2021.

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.