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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that the enrollee needs to relieve the leg pain for her to do therapy The Plan denied your request. The Plan says the enrollee's needs are custodial.
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 from a nursing perspective, the enrollee had stable vital signs, and was treated with Tylenol. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee requires 2-person maximal assist for bed mobility. She would not participate with therapy in the hospital. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or skilled therapy services on a daily 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 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851) suspension sleeve (L2397) and lumbar-sacral orthosis (L0650) provided December 6, 2019.
You asked the Plan to pay for the orthoses. You say that the records should support the necessity of the service in dispute. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851) suspension sleeve (L2397) and lumbar-sacral orthosis (L0650) provided December 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alveoloplasty not in conjunction with an extraction (D7321 x 4), initial 15 minutes of anesthesia (D9222), and 3 additional 15 minutes of anesthesia (D9223).
You asked the Plan to pre-approve the dental services. You say that you are not able to use your CPAP machine due to the pain you are experiencing in your gums. You say that it is embarrassing to not have any teeth. You say that you are limited as to what you can eat. You also say that you need these services so that you can wear dentures. The Plan denied your request. The Plan says alveoloplasty not in conjunction with an extraction is not a covered service. The Plan also says anesthesia is not 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 dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an alveoloplasty not in conjunction with an extraction (D7321 x 4), initial 15 minutes of anesthesia (D9222), and 3 additional 15 minutes of anesthesia (D9223).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on November 7, 2019.
You asked the Plan to pay for the psychotherapy 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 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 service 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 psychotherapy services provided on November 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab tests billed for services provided on January 14, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the documentation did not contain lab results.
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 billed tests are not supported in the medical record. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab tests billed for services provided on January 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9501) provided from February 8, 2020 to February 15, 2020.
You asked the Plan to pay for home infusion therapy. You say that this should be processed as an in-network service. The Plan denied your request. The Plan says this code is not valid for Medicare purposes.
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 S9501 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9501) provided from February 8, 2020 to February 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pegfilgrastim (Neulasta).
You asked the Plan to pre-approve Neulasta. The Plan denied your request. The Plan says medical necessity has not been met as the regimen is low risk for developing febrile neutropenia.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Neulasta. Our physician reviewer found that this request is for Neulasta to prevent neutropenic fever being treated with Carboplatin, Alimta, and Keytruda for metastatic lung cancer. The enrollee has a normal white blood count prior to treatment. There is no indication of fever in the submitted documents. The drug is FDA approved and compendium supported for use as prevention when there is a clinically significant incidence of febrile neutropenia. Per the NCCN Guidelines, the enrollee's chemotherapy regimen is not listed as high or intermediate risk for febrile neutropenia. The use is not listed as not indicated, not supported or not recommended in any of the compendia. Therefore the regimen does not have clinically significant incidence of febrile neutropenia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Neulasta have not been met. Therefore, we decided that the Plan does not have to pre-approve Pegfilgrastim (Neulasta).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (S9500, S9501) provided from January 10, 2020, to January 16, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a Medicare-covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Codes S9500 and S9501 are assigned a status indicator of "I" under the Physician Fee Schedule, which means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (S9500, S9501) provided from January 10, 2020, to January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the routine foot care to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve OON foot care. You say that you need these services to remain ambulatory.
The Plan denied your request. The Plan says these services are now 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 routine foot care to be provided by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zarxio.
You asked the Plan to pre-approve Zarxio. The Plan denied your request. The Plan says the enrollee has not received previous treatment, or intolerance to Neupogen (Filgrastim) and Nivestym (Filgrastim-aafi).
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 Zarxio. Our physician reviewer found that the enrollee has malignant neoplasm of overlapping sites of right bronchus and lung. The Plan requires a trial of Neupogen and Nivestym before they will approve the requested drug. The case file does not contain documentation of trial and failure of Neupogen and Nivestym. The documentation does not support that Neupogen and Nivestym would likely be less effective, or would 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 Zarxio have not been met. Therefore, we decided that the Plan does not have to pre-approve Zarxio.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a retainer crown (D6740) for tooth # 11, a pontic (D6245), and 3 labial veneer (D2962).
You asked the Plan to pre-approve the dental services. You say that you have been diagnosed with multiple Epiphyseal Dysplasia. You say that you have an abnormal tooth root system as a result. You say that you need these services. You also say that you cannot afford to pay for the services if they are not covered. The Plan denied your request. The Plan says there is a yearly allowance of $1,000 for supplemental preventive and comprehensive dental services. The Plan also says that the allowance has been reached.
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 annual allowance of $1,000 has been reached. The record shows that the approval of the retainer crown for tooth # 9 has exhausted the annual allowance. Therefore, we decided that the Plan does not have to pre-approve a retainer crown (D6740) for tooth # 11, a pontic (D6245), and 3 labial veneer (D2962).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exercise bike.
You asked the Plan to pre-approve an exercise bike. You say that an exercise bike is necessary for you to survive. The Plan denied your request. The Plan says Exercise equipment is not primarily medical in nature.
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. Home exercise/ physical therapy equipment that can be obtained without a prescription is considered to be an over the counter supply, is not considered DME, and is therefore, ineligible for coverage. Therefore, we decided that the Plan does not have to pre-approve an exercise bike.
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 the enrollee needs a ventilator and prolonged stay in the hospital. The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current acute care facility.
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 is currently undergoing treatment at an acute care hospital (ACH) following brain surgery due to acute-on-chronic bleeding. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee remains on a ventilator. It is unclear whether the enrollee can be weaned from the ventilator or if he can be safely decannulated. 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. 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 services (CPT 73221) provided on December 23, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed without the appropriate modifier.
The Plan must follow Medicare rules. Medicare rules say that modifiers -LT and -RT are required whenever they are appropriate. We looked at the file and Medicare rules. The records show that an MRI of an upper extremity was performed on December 23, 2019. The use of an anatomical modifier is required for this service to indicate which side the procedure was administered to. The MRI was billed without modifier -LT or -RT. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 73221) provided on December 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 11, 2019.
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 emergency situation, 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 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 laboratory services provided on December 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral exam (D0140) provided on December 31, 2019.
You asked the Plan to pay for the dental service. You say that you were referred to this provider. You say that this visit was for a second opinion to determine if you needed a root canal before a permanent crown was placed. You also say that this exam was done by a specialist as your dentist does not do root canals. The Plan denied your request. The Plan says 2 oral exams per calendar year are covered. The Plan also says that the frequency limit has been exceeded.
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 oral exams are a covered service, the frequency limit of 2 oral exams per calendar year has been exceeded. The record shows that the Plan previously paid for oral exams that you received on May 9, 2019 and November 13, 2019. Therefore, we decided that the Plan does not have to pay for the limited oral exam (D0140) provided on December 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral thermometer (A4931).
You asked the Plan to pre-approve an oral thermometer. You say that you are requesting a reconsideration of the Plan's denial as your son has gone to several pharmacies; however, there were no available thermometers. The Plan denied your request. The Plan says this item is not a covered benefit under your contractual policy.
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 an oral thermometer (A4931).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a donut tailbone pillow.
You asked the Plan to pre-approve a donut tailbone pillow. You say that you are in pain and you need a donut tailbone pillow in order to sit comfortably. The Plan denied your request. The Plan says a donut tailbone pillow is not primarily medical in nature.
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 donut tailbone pillow.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve robotic assisted atrial clip placement.
You asked the Plan to pre-approve robotic assisted atrial clip placement. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that LAAC for non-valvular atrial fibrillation (NVAF) is covered through Coverage with Evidence Development when he patient is enrolled in and the MDT and hospital participate in a prospective, national, audited registry. We looked at the file and Medicare rules. There is no documentation of participation in the required registry. Based on this information, we decided that Medicare rules for coverage of robotic assisted atrial clip placement have not been met. Therefore, we decided that the Plan does not have to pre-approve robotic assisted atrial clip placement.