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

We decided that the Plan does not have to pre-approve continuation of SNF care from August 27, 2021, forward.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on review of the available records, the enrollee, post hip fracture and an SNF rehab stay for three (3) weeks did not meet the Centers for Medicare & Medicaid Services (CMS) coverage criteria for continuation of coverage in an SNF. The enrollee was medically stable. Had no daily skilled nursing needs. While the enrollee required therapies, the enrollee made minimal progress from August 13, 2021 for mobility and for most activities of daily living (ADLs). Three weeks of SNF stay is for uncomplicated hip fracture rehab at SNF is adequate to get patients functional. This enrollee has not been able to make progress. Medicare guidelines expect patients to make a significant progress in a reasonable and predicted period of time which is not the case with this enrollee. The enrollee does not need daily skilled therapies in an inpatient setting. Continuation beyond the date approved was not reasonable and medically necessary for the enrollee's condition in the absence of skilled nursing needs. The enrollee's rehabilitation needs could have been met at a lower intensity level at an long-term care (LTC) facility with intermittent therapies.

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 pre-approve continuation of SNF care from August 27, 2021, forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. The nenrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. 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 requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on December 23, 2020.
You asked the Plan to pay for the services provided. You say that the enrollee relied on the facility to ensure he
would have a vision exam. The Plan denied your request. The Plan says the claim was processed correctly.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case.
The file shows the enrollee received refraction services and bifocals. We looked at the file and the Plan's rules.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the vision services provided on December 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care provided
from August 26, 2021, forward.
You asked the Plan to pre-approve inpatient mental health care. You say that you should not be released into
the community as you could be a harm to yourself or others. The Plan denied your request. The Plan says you
do not have a plan or intent to harm yourself or anyone else, you are not hearing voices telling you to harm
yourself or others, you are not aggressive or violent, there are no medical problems reported, and no severe side
effects from medications. You could be treated in a lower level of care.
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 mental health care. Our physician reviewer found the health plan's denial of continued inpatient psychiatric services is appropriate. You did not appear to require inpatient mental health treatment beyond the date in question as you were not a danger to yourself or others and do not have any auditory or visual hallucinations while being cooperative with
treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve your condition or for the purpose of diagnosis beyond
the date in question. You were treated under an individualized treatment plan alluded to in the record. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided
for the admission, you do not meet the criteria for continued acute inpatient mental health treatment for the
dates in question of August 26, 2021, forward as you were not shown to be a danger to yourself or others. You
were not showing any auditory or visual hallucinations and were cooperative/compliant with treatment while
not showing any threats of safety as you awaited placement.
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 mental health care have not been met. Therefore, we decided that the
Plan does not have to pre-approve continuation of inpatient mental health care provided from August 26, 2021, forward.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq.

You asked the Plan to pre-approve Tecentriq. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the clinical value and effectiveness of Tecentriq for the enrollee's condition have not been demonstrated.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Tecentriq. Our reviewer says that this drug is not medically necessary for the enrollee's condition. Our physician reviewer found the record indicates that the enrollee has Stage IIb T3No squamous cell carcinoma of the lung with programmed death-ligand 1 (PDL1) of 20%. The Food and Drug Administration has not stated that the requested drug is indicated in the enrollee's condition. The Medicare approved cancer compendia do not contain a positive citation for the requested drug in the enrollee's condition. No literature from Medicare care approved cancer journals was submitted for review. The elements of the coverage criteria are not satisfied.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Tecentriq have not been met. Therefore, we decided that the Plan does not have to pre-approve Tecentriq.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided April 16, 2021.
You asked the Plan to pay for the orthoses. You say that please review this claim due to the current Coronavirus pandemic guidelines and reconsider accordingly. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines and the provider is not a Medicare certified durable medical equipment supplier.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided April 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999) and consultation (D9310) provided on November 25, 2020.

You asked the Plan to pay for the preventive procedure and consultation. You say that you did not have a consultation on this date of service. The Plan denied your request. The Plan says these services are not covered benefits under your dental 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 pay for the preventive procedure (D1999) and consultation (D9310) provided on November 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cochlear implant for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria is not met.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not have bilateral moderate-to-profound sensorineural hearing loss. She has mild to moderate less in the right ear. Therefore, the criteria is not met for the implant. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a cochlear implant for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of the health problem.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure remains experimental for back pain. More research is needed to show safety and efficacy of the procedure. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compression device (E0675) and segmental gradient pressure pneumatic appliance (E0673) provided October 19, 2020.

You asked the Plan to pay for the pneumatic compression device and appliance. You say that the DME was prescribed by the doctor and issued to the enrollee for use during their surgery. You are not contracted with the facility or the prescribing physician and do not receive payment from either provider. The Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CMS does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.

In this case, the enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Based on this information, we decided that Medicare rules for coverage of the pneumatic compression device and appliance have not been met. Therefore, we decided that the Plan does not have to pay for pneumatic compression device (E0675) and segmental gradient pressure pneumatic appliance (E0673) provided October 19, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the copayment for the bone mass measurement (procedure code 77080) you had on February 15, 2021.

You asked the Plan to waive the copayment for the bone mass measurement. You say that you thought that you were entitled to a bone mass measurement every two years free of charge. The Plan denied your request. The Plan says that you were charged this copayment correctly

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay $0 copayment for bone mass measurements. 

The Plan says you must pay a $40 copayment for the bone mass measurement because it is considered a diagnostic test. We do not find this argument persuasive. No medical records were provided by the Plan to substantiate that this was ordered as a diagnostic test. Furthermore, the diagnoses billed on the claim (asymptomatic menopausal state and osteoporosis) are not sufficient evidence to determine that the test was ordered as diagnostic. You stated that osteoporosis was diagnosed as a result of this bone mass measurement. The Plan has provided no evidence that you had this diagnosis before this bone mass measurement that would justify their determination that this test was done for diagnostic purposes. That is why we find that you cannot be asked to pay more than $0 copayment for the bone mass measurement. Therefore, we decided that the Plan has to waive the copayment for the bone mass measurement (procedure code 77080) you had on February 15, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation, intraoral x-ray and extractions
provided on April 7, 2021.

You asked the Plan to pay for the limited oral evaluation, intraoral x-ray and extractions. You say that you were
not made aware that the provider was out-of-network. You say that you were informed they accepted the plan
and you cannot afford to pay $445. The Plan denied your request. The Plan says services from an out-of-network
provider are 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.

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
limited oral evaluation, intraoral x-ray and extractions provided on April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99199, S1015, S8301) provided on March 19, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules also say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We asked our coder 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 services. Our reviewer says that the use of code 99199 is not supported by the records provided. Our reviewer found that post-op anesthesia care would not be reported separately. "Anesthesia care is provided by an anesthesia practitioner who may be a physician, a certified registered nurse anesthetist (CRNA) with or without medical direction, or an anesthesia assistant (AA) with medical direction. The anesthesia care package consists of preoperative evaluation, standard preparation and monitoring services, administration of anesthesia, and post-anesthesia recovery care." Therefore, this service would not be covered. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 99199 have not been met. Additionally, codes S1015 and S8301 are assigned a status indicator of "I" under the Physician Fee Schedule, which means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. Therefore, we decided that the Plan does not have to pay for the services (99199, S1015, S8301) provided on March 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the additional routine transportation trips.

You asked the Plan to pre-approve routine transportation trips. You say that you need additional routine transportation to get to all of your Doctor appointments. The Plan denied your request. The Plan says you have exhausted your Plan benefit for routine transportation.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one way trips trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve the additional routine transportation trips.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the lumbar spine for the enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says data needed for management of lumbar pain can be obtained from the approved MRI.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 scan. Our reviewer says that a CT scan of the lumbar spine is not medically reasonable or necessary. Our physician reviewer found an MRI has been approved and would be the most appropriate imaging study. There is no documented concern for trauma or tumor. 

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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the lumbar spine for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zoster vaccine provided on May 5, 2021.

You asked the Plan to pay for the Zoster (shingles) vaccine (90750). You say that you would like the Plan to cover the immunization. The Plan denied your request. The Plan says this vaccine is not covered under your Medicare Part B benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Zoster (shingles) vaccine (90750). The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the Zoster (shingles) vaccine (90750). Therefore, we decided that the Plan does not have to pay for the Zoster vaccine provided on May 5, 2021.

Benefits for the Zoster (shingles) vaccine (90750) may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.