Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary.
 The Plan denied your request. The Plan says the enrollee could be treated in a skilled nursing facility.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient physician three times per week or acute rehab nursing care. While she may benefit from continuing physical and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. We looked at this physician's review, the file, and Medicare rules.  Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules.The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At leastfour weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on September 13, 2018 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you were pre-approved by the member's Primary Physician Group. The Plan denied your request. The Plan says no prior authorization was obtained for these services.
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 physician services provided on September 13, 2018 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on September 20, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
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 noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on September 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued Privigen injections.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this is helpful for treatment of this health problem.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested injections are not medically reasonable or necessary. Our physician reviewer found the review indicates that the documentation does not support that the Privigen is medically reasonable and necessary for the enrollee. The documentation does not support that the Privigen is safe and effective 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve continued Privigen injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOneTouch Ultra Blue test strips for the enrollee.You asked the Plan to pre-approvethese services. The Plan denied your request. The Plan says that there are no medical records and/or certificate of medical necessity provided to show the reason for using this strip.The Plan must follow Medicare rules. Medicare rules say that plans may limit enrollees to preferred providers.The items at issue are OneTouch Ultra Blue test strips. OneTouch Ultra Blue is not a preferred provider with the Plan for diabetic supplies. ACCU-CHEK and Trividia are the preferred providers.Therefore, we decided that the Plan does not have to pre-approveOneTouch Ultra Blue test strips for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approveSNF services. The Plan denied your request. The Plan says that the enrollee's does not have a daily skilled medical or therapy need.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed aboveare 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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services.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-approveskilled nursing facility (SNF) services for the enrollee.
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 clinical documentation provided supports the need for LTACH care. The Plan denied your request. The Plan says the records do not show that it is medically necessary for the enrollee to be in an LTACH in place of an acute care hospital.
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 enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. All medically necessary care is being provided in the current acute care setting. 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 health plan has approved ongoing care in the current acute care 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care provided on March 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for initial hospital care. You say that the services provided were medically necessary. The Plan denied your request. The Plan says the services were provided out of network 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 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 initial hospital care provided on March 15, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 14 and 19.
You asked the Plan to pre-approve the core build up. You say that the enrollee's tooth # 19 has recurrent carries and needs a crown. The Plan denied your request. The Plan says core build up is not a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, 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 core build up (D2950) for teeth # 14 and 19.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6549.You asked the Plan to pre-approvethe compression stockings. You say that you require these stockings to keep the swelling down in your legs.The Plan denied your request. The Plan says these stockings are not covered when used for lymphedema.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vision care to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve vision care. You say that your vision is getting worst and you feel like the in-network providers are not providing the care you need. The Plan denied your request. The Plan says there is an in-network provider, available for these services.
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 vision care to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.You asked the Plan to pre-approve the SNF admission. You say that you are still in need of these services and needs this to be approved.The Plan denied your request. The Plan says the SNF benefit has been exhausted.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from February 8, 2019 to September 1, 2019. The Plan has covered 100 days of SNF care.Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean occlusal guard (D9944).You asked the Plan to pre-approvethe occlusal guard. You say that your providersaid that you are grinding your teeth at night while you are sleeping.The Plan denied your request. The Plan says this service is not covered under your benefit plan.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, per the Office Reference Manual (ORM) the requested items or services arenot among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvean occlusal guard (D9944).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 Power Wheelchair (K0861).
You asked the Plan to pre-approve the Group 3 Power Wheelchair. The Plan denied your request. The Plan says Medicare coverage criteria have not been met.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to a neurological condition, myopathy, or congenital skeletal deformity. The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a Group 3 Power Wheelchair (K0861).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on September 9, 2019 by an out of network (OON) provider.You asked the Plan to pay for physician services. You say that you would like this approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for these services.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 physician services provided on September 9, 2019 by an out of network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe presumptive and definitive drug testing provided on September 9, 2019.You asked the Planto pay forthe drug testing. You say that all necessary documents are included in the file.The Plandenied your request. The Plansaysthere is no valid order for this patient on this date of service.The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered if ordered by a treating provider.In this case, the submitted documents do not appear to include an actual order for this patient for the date of service. Although there is a form which defines the testing included on the practice's custom panel but no document to show that the provider ordered this panel for this patient on this date.Therefore, we decided that the Plandoes not haveto pay forthe presumptive and definitive drug testing provided on September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora Tetanus immunization (90471 and 90714) and a glycosylated hemoglobin test (83036) provided on August 14, 2019.You asked the Plan to pay for the Tetanus immunization and glycosylated hemoglobin test. You say that you would like reconsideration based onthe records submitted. The Plan denied your request. The Plan says the Tetanus vaccine is not covered as a preventative service and the glycosylated hemoglobin test is not a Medicare benefit for the diagnosis listed on the claim.In the absence of injuryor direct exposure to illness, Medicare does not pay for or provide the Tetanus immunization. The rules also say that glycosylated hemoglobin tests are not covered for the diagnosis of diabetes. 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 immunization. Additionally, the claim does not include an appropriate diagnosis for the billing of the glycosylated hemoglobin test Therefore, we decided that the Plan does nothave to pay for a Tetanus immunization (90471 and 90714) and a glycosylated hemoglobin test (83036) provided on August 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
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-approvethe LTACH services. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met in the current 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) following an out-of-hospital cardiac arrest. The enrollee was intubated/ventilated upon presentation and subsequently received a tracheotomy. The enrollee remains on a ventilator and has been started on hemodialysis. Her neurologic status and long-term prognosis appears to be poor. It is unclear when, or if, the enrollee will be able to be weaned from the ventilator. 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 long term care 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-approvelong term acute care hospital (LTACH) services.