Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Osseous surgery (D4261), a bone replacement graft (D4263), and guided tissue regeneration (D4266).

You asked the Plan to pre-approve the dental services. You say that you were advised by a plan representative that the services would be covered under a sub-category. You say that this surgery is preventive in nature as you are trying to save your tooth. You say that most other dental plans cover periodontal surgery. You also say that you feel this would be cheaper than an extraction and replacement of the tooth. The Plan denied your request. The Plan says Osseous surgery is not listed as a covered service. The Plan says that bone replacement graft is not listed as a covered service. The Plan also says that guided tissue regeneration is not listed as a covered service either.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve Osseous surgery (D4261), a bone replacement graft (D4263), and guided tissue regeneration (D4266).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc.
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 services are not covered.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Orthovisc.
Benefits for these services 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ketamine infusions.
You asked the Plan to pre-approve ketamine. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 ketamine. Our reviewer says that ketamine is not medically reasonable and necessary in this case. Our physician reviewer found that this an off-label use of ketamine. While Esketamine is approved for depression, ketamine is not approved for this use. The request 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 ketamine have not been met. Therefore, we decided that the Plan does not have to pre-approve ketamine infusions.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation and set-up of a portable x-ray (Q0092 and R0070) provided on September 13, 2020.
You asked the Plan to pay for the transportation and set-up of a portable x-ray. You say that you would like reconsideration because these codes are billable and separately payable. The Plan denied your request. The Plan says services provided to beneficiaries in a non-covered Skilled Nursing Facility stay should be billed with POS code 32.
The Plan must follow Medicare rules. Medicare rules say that POS code 32 should be used with services for beneficiaries in a non-covered stay. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transportation and set-up of a portable x-ray have not been met. Specifically, this claim was billed with POS code 31 indicating that the member was in a Part A covered stay. Per the Plan, the member was not in a Part A covered stay, therefore POS code 32 would be appropriate. Therefore, we decided that the Plan does not have to pay for the transportation and set-up of a portable x-ray (Q0092 and R0070) provided on September 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
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 services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis. The requested Superion spacer is experimental in nature, as more research is needed to show safety and efficacy. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the placement of an implant body (D6010) and a custom
fabricated abutment (D6057) for tooth # 10.

You asked the Plan to pre-approve the dental services. You say that the enrollee has existing crowns on teeth #
8 and 9, and an existing bridge for teeth # 11 to 14. You say that the implant will assure a long-term retention
of the remaining dentition by maintaining a proper occlusion without disruption of existing restorations. The
Plan denied your request. The Plan says placement of an implant body is not listed as a covered service. The
Plan also says that custom fabricated abutment is not listed as a covered service either.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the
placement of an implant body (D6010) and a custom fabricated abutment (D6057) for tooth # 10.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lubricant (A4402) provided on September 24, 2020.
You asked the Plan to pay for the lubricant. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not include the item billed.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order and proof of delivery for the supplies provided in this case. Specifically, the documentation submitted does not include an order for the lubricant. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for lubricant (A4402) provided on September 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day glucose monitoring system.
You asked the Plan to pre-approve a Freestyle Libre 14 day glucose monitoring system. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested item.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day and use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 14 day glucose monitoring system have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 day glucose monitoring system.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transfer to SNF care.

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 the enrollee does not require inpatient rehabilitation facility (IRF) to SNF transfer. This enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee has no complex wound care or other SN need. The enrollee's functional level 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. Skilled nursing or therapy services are not required on a "daily basis" or as a practical matter on an inpatient basis, in a skilled nursing facility setting. The enrollee's needs are currently being met in an IRF and can continue there until there is a plan for a community or home discharge.

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 transfer to SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis provided on October 14, 2020.
You asked the Plan to pay for the knee orthosis (L1833). You say that the Plan should pay this claim. The Plan denied your request. The Plan says there is a lack of supporting information to support services rendered and no proof of delivery was provided.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery or relevant medical records which support medical necessity for the supplies provided in this case. here is no proof of delivery in the case file and the medical records do not mention knee issues. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the knee orthosis provided on October 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Norco 10-325mg tablets.

You asked the Plan to pre-approve Norco tablets. You say that this medication is medically necessary. The Plan denied your request. The Plan says Norco is not eligible for coverage under the Part B medical benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 Norco 10-325mg tablets.

Benefits for Norco tablets 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care.

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 at the time of admission, you required skilled rehab services to improve function due to weakness and deconditioning. There were no skilled nursing needs. You did not require any skilled nursing or rehab services on a daily basis. You were not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living (ADLs). You did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, you did not require any skilled services on an inpatient basis, at a SNF level of care. You did not have any parental medications, complex wound care or nutrition given via a feeding tube. You received skilled care with minimal improvement. Her function had plateaued and you did not require any further inpatient skilled rehab services. Your function was at or near your prior level of function and you could be discharged to a lower level of care for further services. You required custodial services. The denial for further inpatient skilled care is upheld.

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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 30, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.
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 laboratory services. 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 laboratory services provided on October 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bath/shower 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 services are not covered.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a bath/shower bench.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that there are no lower levels of care that will accept the enrollee due to her complicated medical care needs. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current acute setting.
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 physician reviewer found that the enrollee underwent a coronary artery procedure, complicated by sternal dehiscence. Pulmonary medicine progress notes documented that the enrollee remains on trilogy ventilation. There is documentation supporting that the enrollee is not capable of being weaned at this time with trilogy ventilation dependence. She is receiving appropriate care at the present acute care hospital. She does not require services at the LTACH that are not available at the acute care hospital where she is 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. Therefore, the requested LTACH services are 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mobile imaging services provided on July 7, 2020.
You asked the Plan to pay for the imaging services. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. In this case place of service (POS) code 31 would indicate that the enrollee was in a Part A covered stay. This means that the setup and transport would not be billable to the plan by the provider, but by the SNF. Therefore, reporting POS code 31 is not appropriate. The correct POS code would be 32, which indicates a non-covered SNF stay. Based on this information, we decided that Medicare rules for coverage of the imaging services have not been met. Therefore, we decided that the Plan does not have to pay for the mobile imaging services provided on July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network provider.
You asked the Plan to pre-approve the office visit. You say that this provider is a five-star urologist. You say that you need urgent help, and he is the best one for the job. The Plan denied your request. The Plan says services are available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray, laboratory services, therapeutic, prophylactic, or diagnostic injection, ED visit, and Ceftriaxone sodium injection provided on November 12, 2019.
The enrollee asked the Plan to pay for the chest x-ray, laboratory services, therapeutic, prophylactic, or diagnostic injection, ED visit, and Ceftriaxone sodium injection. The enrollee says that their hospice care was revoked on November 12, 2019. The Plan denied the enrollee's request. The Plan says the Medicare Hospice benefit, through fee-for-service Medicare, covers all Hospice care from the effective date of election to the date of discharge or revocation. The Plan also says that during the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness starting on the date of the Hospice election until the first day of the month following the month in which Hospice is revoked or discharged.
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 chest x-ray, laboratory services, therapeutic, prophylactic, or diagnostic injection, ED visit, and Ceftriaxone sodium injection provided on November 12, 2019.