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

We decided that the Plan does not have to pay for the laboratory service (84999) rendered by the out-of-network (OON) provider on November 4, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the laboratory service (84999) rendered by the out-of-network (OON) provider on November 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the replacement of missing or broken teeth on a complete denture (D5520) provided on April 2, 2021.
You asked the Plan to pay for the teeth replacement. You say that you were advised that you had an allowance of $2,000 instead of $1,500. The Plan denied your request. The Plan says your $1,500 calendar year maximum has been met. The Plan also says that you were correctly advised that you had a $1,500 calendar year maximum allowance.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $1,500 combined allowance for supplemental preventive and comprehensive dental services every year. The contract says that you are responsible for any amount over and above the allowance amount. The record shows that you met the annual maximum benefit while processing this claim for the April 2, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the replacement of missing or broken teeth on a complete denture (D5520) provided on April 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lumigan 0.01% solution.
You asked the Plan to pre-approve Lumigan. You say that Lumigan is medically necessary. The Plan denied your request. The Plan says this drug 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 Lumigan 0.01% solution.
Benefits for Lumigan 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the direct skilled nursing services of a RN provided from March 15, 2021, to April 12, 2021 by an OON provider.
You asked the Plan to pay for the direct skilled nursing services of a RN. The Plan denied your request. The Plan says the rendering provider is non-contracted, and there is not a referring provider. The Plan also says that the provided services were not authorized.
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
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 the direct skilled nursing services of a RN
provided from March 15, 2021, to April 12, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic casts (D0470).
You asked the Plan to pre-approve the diagnostic casts. You say that everything is supposed to be covered under your dental plan within the benefits. The Plan denied your request. The Plan says this service is not a covered benefit.
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 diagnostic casts (D0470).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen and oxygen equipment provided on September 14, 2020, to November 14, 2020.

You asked the Plan to pay for the oxygen and oxygen equipment. You say that you believe that oxygen therapy was medically necessary and should be a covered benefit to help the enrollee's conditions. The Plan denied your request. The Plan says the items received are not a covered benefit when not rented.

The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.  

To qualify for home oxygen, the patient must meet one of the following blood gas levels:

1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;

2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep; 

3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise;

4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia.

For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage.

We looked at the file and Medicare rules. Review of the file shows that the oxygen and oxygen equipment was not rented. Payment is not made for purchases of this type of equipment. Based on this information, we decided that Medicare rules for coverage of the oxygen and oxygen equipment have not been met. Therefore, we decided that the Plan does not have to pay for the oxygen and oxygen equipment provided on September 14, 2020, to November 14, 2020.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for the individual psychotherapy (90832) provided January 2, 2020.

You asked the Plan to pay for the psychotherapy. You say that this appeal should be granted because the services provided were medically necessary and meet all applicable professionally recognized standards of healthcare. The Plan denied your request. The Plan says that Medicare payment for clinical psychologist's services is limited to treatment by practitioners with a Psychology Doctoral degree, Licensed or certified in the State, with patient consent, and consult with the attending or primary care physician

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, specific records or information was required to clarify and substantiate the plan's denial. A request was sent August 20, 2021, with a due date of August 23, 2021. As of the date of this letter, the plan has not responded to our request and/or submitted required information. Therefore, we decided that the Plan has to pay for the individual psychotherapy (90832) provided January 2, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a home ventilator for the enrollee.

You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says that the records are not sufficient and detailed enough.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 ventilator. Our reviewer says that the requested ventilator is medically reasonable and necessary. Our physician reviewer found the enrollee has amyotrophic lateral sclerosis (ALS) with severe restrictive lung disease. The forced vital capacity (FVC) is 32% of predicted, which is severely reduced and requires urgent treatment. The enrollee requires a 24 hour per day ventilator support, with face mask at night, and sip-and-puff ventilation during the day. Alarms and battery backup are necessary. Bilevel positive airway pressure (BiPAP) cannot provide this level of support. 

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 ventilator have been met. Therefore, we decided that the Plan has to pre-approve a home ventilator for the enrollee.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.
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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.
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.
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 you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
While the enrollee may need physical and/or occupational therapy, there is no documented need for an
intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will
be able to fully participate in - and benefit from - the intensive rehabilitation therapy program provided in an
IRF.
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.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy.

You asked the Plan to pre-approve the requested services. You say that the enrollee continues to be short on her goals. The Plan denied your request. The Plan says the enrollee does not need skilled physical therapy at home.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 requested services. Our physician reviewer found that the enrollee is at a standby assist level for standing up, transfers, and sitting down. She does not have documented skilled physical therapy needs. She is functioning at a level that no longer necessitates home 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health physical therapy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection procedures represented by codes 38792-LT and 38792-RT provided on February 8, 2021.

You asked the Plan to pay for codes 38792-LT and 38792-RT. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. 

We find that 2 units of CPT code 38792 are not supported in the medical record. The file shows that code 38792 has a bilateral surgery indicator of "1." This means that code 38792 must be reported with "1" unit of service and modifier 50. Based on this information, we decided that Medicare rules for coverage of codes 38792-LT and 38792-RT have not been met. Therefore, we decided that the Plan does not have to pay for the injection procedures represented by codes 38792-LT and 38792-RT provided on February 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee requires interdisciplinary therapy care and daily oversight by a physician. The Plan denied your request. The Plan says there are no complex nursing or rehab needs.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 physician reviewer found that the enrollee was admitted to the acute care hospital for respiratory failure, pneumonia, and pleural effusion Medical problems are stable. There are no complex nursing needs. She does not require treatment by multiple therapies, including either physical or occupational therapy, and an intensive rehabilitation therapy program.
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.
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 the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary
approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF level of 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
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve Purewick catheter.

You asked the Plan to pre-approve Purewick catheter. You say that you require full assistance from your bed to the chair. The Plan denied your request. The Plan says that the requested item is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that Purewick catheter is covered for certain indications. 

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 Purewick catheter. Our reviewer says that the documentation does support that the requested Purewick catheter is medically reasonable and necessary. Our physician reviewer found you have urinary incontinence, impaired mobility, and are wheelchair dependent. You have a diagnosis/condition that meets criteria for the requested Purewick catheter. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Purewick catheter have been met. Therefore, we decided that the Plan has to pre-approve Purewick catheter.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the records received show that the enrollee's condition has improved and is no longer a threat to yourself or others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services.
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the enrollee. It is not expected this enrollee would improve in a reasonable period of time as he is not showing any dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors. This patient was compliant with treatment and having no side effects to the medication. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he does not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. Our physician reviewer found the enrollee's condition does not meet Medicare criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Imvexxy 10 mcg starter pack.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is intended for patient self administration.

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 an Imvexxy 10 mcg starter pack.