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

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs appear to be custodial and, as a practical matter, can be 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.

You asked the Plan to pre-approve Keytruda. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 Keytruda. Our reviewer says that the medication is not medically necessary. Our physician reviewer found as microsatelite stable MSS and Tumor mutaional burdern<10(8), Keytruda is denied per compendia and literature. Other mutations can't serve to authorize Keytruda for pancreas cancer. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse more for the oxygen concentrator you received from a
non-contracted durable medical equipment company on January 15, 2021.
You asked the Plan to reimburse more for the oxygen concentrator. You say that you had to purchase this item
out-of-network because there were no other providers available. You would like additional reimbursement for
this item. The Plan denied your request. The Plan says you were reimbursed correctly for this item.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for durable medical equipment.
Records show that you purchased an oxygen concentrator. However, Medicare only covers oxygen equipment
as a monthly rental, not as a purchase. The monthly allowed rental amount is $104.75. According to your
contract, you have to pay 20% coinsurance for durable medical equipment. The Plan appropriately reimbursed
you $83.81 ($104.75 x 80%). Therefore, we decided that the Plan does not have to reimburse more for the
oxygen concentrator you received from a non-contracted durable medical equipment company on January 15,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoroscopic guidance for needle placement services provided on March 19, 2021.

You asked the Plan to pay for the fluoroscopic guidance for needle placement services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed with mismatched diagnosis codes.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that the fluoroscopic guidance for needle placement services are not supported in the medical record. Specifically, these services were billed with diagnosis codes M25.552 (Pain in left hip), M25.551 (Pain in right hip), Unilateral primary osteoarthritis, left hip), and M16.11 (unilateral primary osteoarthritis, right hip).

Diagnosis codes should indicate laterality, specifying whether the condition occurs on the left, right, or is bilateral. It is not appropriate to report unspecified, or left and right diagnosis codes when a more specific (bilateral) code is available. This means there was a more appropriate diagnosis code to be billed for these services rendered. Based on this information, we decided that Medicare rules for coverage of the fluoroscopic guidance for needle placement services have not been met. Therefore, we decided that the Plan does not have to pay for the fluoroscopic guidance for needle placement services provided on March 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341 x2) provided on January 26, 2021.

You asked the Plan to pay for periodontal scaling and root planing. You say that you did not know your dental plan changed and the service was not covered. The Plan denied your request. The Plan says the service at issue 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 pay for periodontal scaling and root planing (D4341 x2) provided on January 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transfer bench.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the item is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a transfer bench.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient pathology tests (88368, 88305, 88342, 88369)
provided on January 20, 2021, by an OON provider.
You asked the Plan to pay for outpatient pathology tests. You say that the services were medically necessary.
The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services
rendered by an out-of-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 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. The records provided for review do not show that the services at issue were urgent or
emergent. 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 outpatient pathology tests (88368, 88305, 88342, 88369)
provided on January 20, 2021, by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy.

You asked the Plan to pre-approve proton beam radiation therapy. You say that the requested proton beam radiation therapy is medically necessary. The Plan denied your request. The Plan says the requested proton beam radiation therapy is not medically necessary.

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 proton beam radiation therapy. Our reviewer says that the requested proton beam radiation therapy is not medically necessary. Our physician reviewer found proton therapy for prostate cancer is not experimental, and in fact is an accepted treatment approach. While I do not think that proton therapy is an experimental therapy, any potential benefit or detriment of proton therapy over standard IMRT is an investigational question (being pursued in randomized studies- i.e. for intermediate to low risk prostate cancer - https://clinicaltrials.gov/ct2/show/NCT01617161 -" Proton Therapy vs. IMRT for Low or Intermediate Risk Prostate Cancer (PARTIQoL)" ). Other treatment approaches (IMRT +/- IGRT) are also highly effective and well tolerated.

Thus, whether proton therapy affords a benefit over other standard approaches (IMRT/IGRT) for prostate cancer is an area of investigation and remains controversial. Particularly with the delivery of relatively low dose of radiation (with a plan to boost using brachytherapy), the risk of GI/rectal toxicity is low such it is even more unlikely that there would be a potential benefit from proton therapy. 

To date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam radiation therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the additional periapical x-rays (D0230 x 3) provided on March 4, 2021.
You asked the Plan to pay for the dental services. You say that you have not had x-rays done since 2019. You also say that you cannot afford to pay for these services. The Plan denied your request. The Plan says 1 periapical x-ray is covered per calendar year. The Plan says that the frequency limit has been exceeded. The Plan also says that limited oral evaluation is not listed as 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 and periapical x-ray is listed as a covered service, frequency limit has been exceeded. The record shows that the Plan paid for the initial periapical x-ray that you received on the date of service in this case. Additionally, limited oral evaluation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the additional periapical x-rays (D0230 x 3) provided on March 4, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc.

You asked the Plan to pre-approve Synvisc. You say that the requested Synvisc is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Monovisc first.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Synvisc. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of Monovisc first before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). In this case, the Plan's required drug(s) would not 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 Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the localized delivery of antimicrobial agents (D4381 x 3), the drugs or medicaments (D9630), the gingival irrigation (D4921 x 2), the scaling and root planing (D4341 x 2), and the extraction (D7210) provided on February 22, 2021 by the out of network provider.
You asked the Plan to pay the full amount for the dental services. You say that you were deceived by the dental office. You say that they did not inform you that they did not have the insurance coverage. The Plan denied your request.
The Plan says out of network providers may bill you for any amount greater than what the plan pays. The Plan says that localized delivery of antimicrobial agents cannot be billed the same days scaling and root planing. The Plan also says that gingival irrigation is not listed as 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 and the services are listed as covered, out of network providers may bill you for any amount greater than what the plan pays. The record shows that the Plan paid the allowed amount for the scaling and root planing, and the extraction. The Evidence of Coverage clearly states that localized delivery of antimicrobial agents cannot be used the same date as scaling and root planing. Additionally, drugs or medicaments, and gingival irrigation are not listed as covered services. Therefore, we decided that the Plan does not have to pay more for the localized delivery of antimicrobial agents (D4381 x 3), the drugs or medicaments (D9630), the gingival irrigation (D4921 x 2), the scaling and root planing (D4341 x 2), and the extraction (D7210) provided on February 22, 2021 by the out of network provider.
Your complaint about being deceived by the dental office is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the Vertiflex device. You say that The Vertiflex device is medically necessary for the enrollee. The Plan denied your request. The Plan says the Vertiflex device is experimental and is not covered by Medicare.
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 Vertiflex device. Our reviewer says that this device is not covered by Medicare. Our physician reviewer found The Vertiflex device is experimental. More research is needed to show safety and efficacy. 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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
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 IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.

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 you were admitted for knee replacement and have been discharged home with home health physical therapy referral. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. Although you do require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. In conclusion, there is not a reasonable expectation that you 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: 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 IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 patient was admitted for surgical repair of a hip fracture after a fall and has been discharged to skilled nursing facility. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical
therapy or occupational therapy, and an intensive rehabilitation therapy program. 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. In conclusion, 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services and family psychotherapy services provided from June 27, 2020, to December 16, 2020.
You asked the Plan to pay for the psychotherapy and family psychotherapy. You say that the services you rendered are not part of the enrollee's hospice services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the psychotherapy services and family psychotherapy services provided from June 27, 2020, to December 16, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 18 additional home health visits with the out-of-network provider.
You asked the Plan to pre-approve 18 additional home health visits with the out-of-network provider. You say that the 18 additional home health visits with the out-of-network provider are medically necessary. The Plan denied your request. The Plan says the 18 additional home health visits with the out-of-network provider are not medically necessary as the enrollee can safely transfer to an in-network provider.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 18 additional home health visits with the out-of-network provider. Our reviewer says that the 18 additional home health visits with the out-of-network provider are not medically necessary as the enrollee can safely transfer to an in-network provider. Our physician reviewer found based on the documentation provided, the enrollee does not have an emergent or urgent condition. The enrollee's care needs are foreseeable. As such, use of an OON provider is not 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 18 additional home health visits with the out-of-network provider have not been met. Therefore, we decided that the Plan does not have to pre-approve 18 additional home health visits with the out-of-network provider.