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

We decided that the Plan does not have to pre-approve SNF admission and services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee needs therapy to get stronger. The Plan denied your request. The Plan says the enrollee does not require daily skilled nursing or therapy services on an inpatient basis.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that the enrollee is at total assist for activities of daily living. She is unable to initiate voluntary movement throughout bilateral upper and lower extremities, and the torso. This enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. Her functional status does not require skilled therapy services of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment at a SNF level. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a SNF. As a practical matter this patient does not require the necessary services 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ajovy 225 MG/1.5 ML syringe.
You asked the Plan to pre-approve Ajovy. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says Ajovy is not covered under the enrollee's Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ajovy 225 MG/1.5 ML
syringe.
Benefits for Ajovy may be available under Medicare Part D. Contact the Plan that administers Part D benefits
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nerve block for the enrollee.
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation received does not show that appropriate conservative measures have been taken.
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 block. Our reviewer says that the requested block is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has not had an adequate trial of conservative therapy which could include physical therapy, TENS, Chiropractic or other physical medicine modalities. Therefore, the criteria of the LCD are not met at this point and the requested procedure is therefore deemed, not medically reasonable or 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 block have not been met. Therefore, we decided that the Plan does not have to pre-approve a nerve block for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean electronic connection between wheelchair controller and one power seating system motor (E2310).You asked the Plan to pre-approvethe electronic connection device. The Plan denied your request. The Plan says this 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 the electronic connection device. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the enrollee meets criteria for a group 3 power wheelchair. She has cerebral palsy and is non-ambulatory. She has lower extremity edema and a history of skin breakdown and requires the features of a group 3 power wheelchair. However, she has diplegic cerebral palsy affecting her lower extremities. She has adequate upper extremity strength without reported range of motion deficit, spasticity, or coordination impairment that would prevent her from using standard controls for operating the additional features of her wheelchair. For these reasons, the requested device is not considered medically reasonable or 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 electronic connection device have not been met.Therefore, we decided that the Plan does not have to pre-approvean electronic connection between wheelchair controller and one power seating system motor (E2310)
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and coinsurance for a Computed Tomography (CT) scan (74177) provided on August 28, 2019.
You asked the Plan to waive the deductible and coinsurance for the CT scan. You say that the provider told you the service would be covered. The Plan denied your request. The Plan says the service was covered but the member is still responsible for a coinsurance and deductible per the EOC.
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 a $500 deductible, and then a 5% coinsurance for Advanced Imaging. You have been asked to pay the remaining $200.98 of the $500 deductible, and a 5% coinsurance for the CT scan. the CT scan falls within the Advanced Imaging 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 deductible and coinsurance for a Computed Tomography (CT) scan (74177) provided on August 28, 2019.
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 skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee presented to the emergency department from SNF due to cough and shortness of breath for 3 days as well as desaturation to 82%-83%. She has bilateral lower extremity edema and extravasation of contrast right hand from prior scans. Chest x-ray reveals congestive heart failure and pulmonary edema with bilateral pleural effusions. In the emergency room she had low blood pressure and transcutaneous pacemaker initiated. She has undergone dialysis. The enrollee was admitted to acute care for weakness, bradycardia, hyperkalemia and needed urgent hemodialysis. Based on the documentation provided, this enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have a tracheostomy tube, complex wound care or other SNF level skilled nursing need.
This enrollee is near functional baseline and does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a daily basis. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a skilled nursing facility (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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-network exception for medical services to be provided by the out of network provider.
You asked the Plan to pre-approve the in-network exception. The Plan denied your request. The Plan says an in-network exception is not indicated for services that are available in plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan does offer a point of service option for certain services. 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 an in-network exception for the requested services. Therefore, we decided that the Plan does not have to pre-approve an in-network exception for medical services to be provided by the out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device (22869).
You asked the Plan to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device. You say that this is medically necessary. The Plan denied your request. The Plan says there is a lack of evidence to support that interspinous spacer devices are as safe and effective as the gold standard of decompression.
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 insertion of interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed before this can be considered 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 insertion of interlaminar/interspinous process stabilization/distraction device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for collagen dressing (A6021) and gauze (A6219) provided on August 30, 2019.You asked the Plan to pay for the collagen dressing and gauze. You say that per Medicare guidelines, this claim was denied in error. The Plan denied your request. The Plan says Medicare rules for payment of these services have not been met.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that the collagen dressing and gauze was used in a SNF or hospital. Therefore, we decided that the Plan does not have to pay for collagen dressing (A6021) and gauze (A6219) provided on August 30, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary/rest home visit for the evaluation and management of an established patient (99337) provided by the out of network provider at the facility on September 19, 2019.
You asked the Plan to pay for these services. You say that there is a medical necessity pre-established with the patient and the facility to provide services to the patients needing care. The Plan denied your request. The Plan says the services were not emergent or urgent in nature and were rendered by a nonparticipating provider in a non-participating facility 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 providers in this case are not network providers with the Plan. The Plan has network providers available who can provide 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 domiciliary/rest home visit for the evaluation and management of an established patient (99337) provided by the out of network providers on September 19, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One (J7325).
You asked the Plan to pre-approve Synvisc-One. You say that this is medically necessary and you previously received this drug in April of 2019. The Plan denied your request. The Plan says you have not tried Orthovisc and Monovisc as required by step therapy rules.
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-One. Our reviewer says that the criteria for coverage of Synvisc-One have not been met. Our physician reviewer found the Plan requires a trial of drugs Orthovisc and Monovisc first before they will approve the requested drug, Synvisc-One. The provided medical records do not indicate that you have tried and failed the required drugs or that the Plan's required drugs would likely be less effective or likely have adverse effects for you. 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-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One (J7325).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on May 22, 2019 by the out of network provider.
You asked the Plan to pay for an office visit. You say that you received a bill and you feel it should be paid. The Plan denied your request. The Plan says based on your contract, the plan covers only emergency or urgently needed care from an out-of-network provider. The Plan says that if you need care that the Plan covers and our network providers cannot give it to you, you can get the care from an out-of-network provider. The Plan also says that prior authorization from the plan is required for out-of-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 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 has network providers available who can provide 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 an office visit (99214) provided on May 22, 2019 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional resin based composites provided on August
26, 2019.
You asked the Plan to pay for the resin based composites. You submitted your bill for review. You say that the
Plan shouldn't have paid such a small amount. The Plan denied your request. The Plan says only 2 fillings are
allowed per calendar year.
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 plan also has a maximum benefit
amount of 2 fillings per calendar year. The additional resin based composites are not covered because the Plan
paid for two composites, which exhausted your benefit. Therefore, we decided that the Plan does not have to
pay for the additional resin based composites provided on August 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pay foran oxygen concentrator provided to the enrollee on August 23, 2019.You asked the Planto pay forthe concentrator. You say that this should be paid for.The Plandenied your request. The Plansaysthere are no respiratory or cardiovascular concerns addressed in the enrollee's review of system or the physical exam.The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.  To qualify for home oxygen, the patient must meet one of the following blood gas levels:
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep; 3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise;4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia.For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage.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 concentrator. Our reviewer says that the services at issue in this case werenot medically reasonable or necessary. Our physician reviewer found there are no recent oximetry or blood gas data (within the past 10 years) documenting hypoxemia. In 2009, overnight oximetry showed hypoxemia, but clinical notes show no consideration of obstructive sleep apnea as a possible cause for the hypoxemia (the patient's BMI is 38). Medicare does not ordinarily cover supplemental oxygen without PAP therapy when caused by sleep apnea, because it is ineffective. Polysomnography should be considered for this enrollee. With the information available, supplemental oxygen is not 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 concentrator have not been met.Therefore, we decided that the Plandoes not haveto pay foran oxygen concentrator provided to the enrollee on August 23, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora Tetanus vaccination (90714 and 90472) provided on September 19, 2019.You asked the Plan to pay for the Tetanus vaccination. You say that you would like reconsideration because the vaccination should be included in the wellness visit. The Plandenied your request. The Plan says this vaccine is not covered under your medical benefit, but may be eligible under your prescription drug benefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tetanus vaccination. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Tetanus vaccination. Therefore, we decided that the Plan does not have to pay for a Tetanus vaccination (90714 and 90472) provided on September 19, 2019. Benefits for the Tetanus vaccination may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 17, 2019.You asked the Plan to pay for the physician's services.The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 did not pre-approve the servicesat issue. We found no exception that would requirethe Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician'sservices provided on September 17, 2019.