Persius/hicric huggingface dataset:
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 the health plan's denial of LTACH coverage should be upheld. The enrollee is
currently undergoing treatment at an ACH for ongoing shortness of breath following a recent COVID-19
infection. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that
are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for
any ongoing LTC needs.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second Zilretta injection.
You asked the Plan to pre-approve a second Zilretta injection. You say that this is the only medication that has worked. The Plan denied your request. The Plan says only one injection of Zilretta is FDA-approved.
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 a second Zilretta injection. Our reviewer says that the requested use of Zilretta is not supported. Our physician reviewer found repeat Zilretta injections for knee pain are not FDA-approved. Repeat administration of this medication is considered experimental. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a second Zilretta injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a second Zilretta injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided December 11, 2020.
You asked the Plan to pay for the therapeutic continuous glucose monitor. You say that this service was medically necessary. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician.
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 relevant medical records which support medical necessity for the supplies provided in this case. In this case, the record does not contain medical records which corroborate that the criteria for a continuous glucose monitor have been met. 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 therapeutic continuous glucose monitor provided December 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
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 you do not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met. We looked at the file and Medicare rules. The records show that you are not insulin-treated. 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 Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epidiolex.
You asked the Plan to pre-approve Epidiolex. You say that the medication is necessary. The Plan denied your
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 Epidiolex.
Benefits for Epidiolex 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for travel costs for transplant surgery follow-up provided on January 12, 2021, by an out of network (OON) provider.
You asked the Plan to pay for travel costs for transplant surgery. You say that you want this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained for these transplant services; therefore, you cannot be reimbursed for services related to this transplant.
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. You did not request prior authorization with the Plan for any services related to a transplant you previously had covered. 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 travel costs for transplant surgery follow-up provided on January 12, 2021, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the cataract surgery provided on August 19, 2020.

You asked the Plan to reimburse you for the cataract surgery. You say that you prepaid for the surgery and you want to be reimbursed. The Plan denied your request. The Plan says they paid the provider the Medicare allowable amount for the services.

Medicare rules state that Plans must provide clear contract information. The Plan contract states a cost share will be charged for each outpatient service based on the Medicare allowable rate and the claim submitted by your provider. In this case you pre-paid the provider for this surgery. The Plan has paid the Medicare allowable rate to the facility and the provider. Any charges paid by you over that rate should be reimbursed by the provider, not the Plan. As the provider is out of network, the Plan cannot compel the provider to reimburse you. Therefore, the Plan is not required to reimburse you further for these services. Therefore, we decided that the Plan does not have to reimburse you for the cataract surgery provided on August 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from October 31, 2020, to November 29, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient SNF level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy 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 the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from October 31, 2020, to November 29, 2020.
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 the health plan's denial of LTACH coverage should be upheld. The enrollee is currently undergoing treatment at an ACH. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs. 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: 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 necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care facility. The enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee 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. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI scan of a joint of the upper extremity (73223).
You asked the Plan to pre-approve an MRI of the left shoulder. You say that the requested service is necessary care for the enrollee. The Plan denied your request. The Plan says the requested service is not reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the left shoulder. Our reviewer says that the requested service is not medically reasonable or necessary at this point. Our physician reviewer found that the enrollee has documented low back pain and a prior MRI which shows multi-level degenerative changes. There is no history and physical exam that supports a left shoulder MRI. There is no documented indication for a left shoulder MRI. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the left shoulder have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI scan of a joint of the upper extremity (73223).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the SelectMDx testing provided on January 19, 2021.
You asked the Plan to pay for the testing. 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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 74-year-old male with a PSA of 7.6 and exam findings not suspicious for prostate cancer. The enrollee was requested to undergo a screening investigational test which would not likely produce significant change in outcome over biopsy and surveillance based on current evidence and does not rule out aggressive prostate cancer. Therefore, this request for SelectMDx is not medically reasonable and 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the SelectMDx testing provided on January 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a chair lift for stairs (E0627).
You asked the Plan to pre-approve the chair lift. You say that the chair lift is medically necessary. The Plan denied your request. The Plan says this is not a covered item.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift 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 chair lift for stairs (E0627).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor.

You asked the Plan to provide a therapeutic continuous glucose monitor. You say that because of medical conditions a CGM would greatly improve the enrollee's diabetes management and provide ease to caregivers in completing this necessary task. The Plan denied your request. The Plan says criteria is not met for a CGM.

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, use insulin with at least three daily injections, or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a face down recovery pillow received from May 6, 2020 to June 29, 2020.

You asked the Plan to pay for the pillow. You say that this is medically necessary. The Plan denied your request. The Plan says this is a precautionary device that can also be used for purposes other than the treatment of an illness or injury.

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. The website for this equipment states that it is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for a face down recovery pillow received from May 6, 2020 to June 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and bitewing x-rays (D0274) provided on October 19, 2020.
You asked the Plan to pay for the exam and x-rays. You say that you needed to have these services again within this time period because you saw a new dentist and they were necessary for you to start a new treatment plan. The Plan denied your request. The Plan says these services were provided in a frequency that exceeds what is allowed by the Plan. You previously had both of these services performed in February 2020. Bitewing x-rays may only be covered once per plan year. Comprehensive evaluations may only be covered once every three plan years.
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 items or services are requested in a frequency that is not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and bitewing x-rays (D0274) provided on October 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation and panoramic xray
provided on May 20, 2020.
You asked the Plan to pay for the comprehensive periodontal evaluation and panoramic x-ray. You say that you
thought that these services would be covered. The Plan denied your request. The Plan says benefits for these
services are limited to one time per 36-month period.
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, you are limited to no more than one
comprehensive, detailed/extensive, or periodontal exam in any 36-month period, and you are limited to no
more than one full mouth set of x-rays in any 36-month period. The record shows that you received a
comprehensive oral evaluation and panoramic x-ray on August 20, 2019, and your comprehensive,
detailed/extensive, or periodontal exam and full mouth x-ray benefits have been exhausted. Therefore, we
decided that the Plan does not have to pay for the comprehensive periodontal evaluation and panoramic x-ray
provided on May 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided October 2, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the services billed.
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 CPT code G0483 is not supported in the medical record. Specifically, the place of service listed on
the claim (81, laboratory) does not match the place of service the records describe (11, office setting). Based on
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore,
we decided that the Plan does not have to pay for lab services (G0483) provided October 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) for a power wheelchair.
You asked the Plan to pre-approve the power seat elevation system. You say that this feature is medically necessary. The Plan denied your request. The Plan says this accessory is not covered.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. We looked at the file and Medicare rules. A power seat elevation feature is requested. This is not a covered item. Based on this information, we decided that Medicare rules for coverage of the power seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300) for a power wheelchair.