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

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says this request does not meet the requirements for approval.
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 was admitted with acute on chronic respiratory failure due to chronic obstructive pulmonary disease and pain from stage IIIb anal cancer. The enrollee does not have complex wound care needs and is not on a ventilator. The record does not indicate that daily physician services are needed. The enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility.
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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the device. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a lumbar eSI is covered when specific criteria are
met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of lumbar
radiculopathy with pain despite physical therapy. The records do not support clear radicular pain with findings
on exam or on magnetic resonance imaging (MRI) showing nerve compression. The criteria for coverage are
not met and the ESI is therefore not reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a lumbar epidural steroid injection (ESI).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services you received on April 17, 2021.
You asked the Plan to waive the copayment for the ER services. You say that you believe the facility where you received care was an urgent care center, not an ER. The Plan denied your request. The Plan says they have confirmed that the facility is an ER. The facility stated that they do not have an urgent care facility at the location where you received services, only an emergency room. Plan says that you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency room services.
You have been asked to pay a $90 copayment for the ER services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room (ER) services you received on April 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewing radiographic images (D0274), and topical application of fluoride varnish (D1206) provided on April 5, 2021.
You asked the Plan to pay for bitewing radiographic images, and topical application of fluoride varnish. You say that you disagree with the Plan's denial of the services. The Plan denied your request. The Plan says the services at issue are not covered benefits.
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 pay for bitewing radiographic images (D0274), and topical application of fluoride varnish (D1206) provided on April 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two resin-based composites (D2393 x2) provided on October 29, 2020 by an OON provider.

You asked the Plan to pay for the resin-based composites. You say that you were not aware that the treating provider was OON. You also say that you were never advised that these services would not be covered as in-network. The Plan denied your request. The Plan says the treating provider does not have a contract with the Plan as a participating provider and is allowed to bill the difference of the allowed amount and their billed amount to you.

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 responsible for the $100 deductible, a 20% coinsurance, plus the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay for the two resin-based composites (D2393 x2) provided on October 29, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator.
You asked the Plan to pre-approve the home ventilator. You say that you would like reconsideration because the member meets criteria for the requested home ventilator. The Plan denied your request. The Plan says the requested ventilator is not medically reasonable and necessary.
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 home ventilator. Our reviewer says that the request home ventilator is not medically necessary. Our physician reviewer found the prescribed settings can be provided by certain bilevel positive airway pressure (BiPAP) devices, and Medicare does not cover a home ventilator when used as BiPAP.
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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the home ventilator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methotrexate.
You asked the Plan to pre-approve Methotrexate. The Plan denied your request. The Plan says Methotrexate to be administered at home is not covered under the Part B 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 Methotrexate.
Benefits for Methotrexate 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital level of care for laminotomy surgery.
You asked the Plan to pre-approve inpatient hospital care. You say that the inpatient stay is needed to help with the enrollee's health. The Plan denied your request. The Plan says the denial of authorization for inpatient level of care is correct, because the documentation does not support the expectation that the enrollee will require a greater than 2-midnight hospital stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 hospital care. Our reviewer says that the enrollee does not meet the Medicare criteria for inpatient level of care for this surgery.
Our physician reviewer found the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. This procedure was approved as an ambulatory procedure. There is no documentation to support the expectation that the enrollee will require a greater than 2-midnight hospital stay. 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 hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital level of care for laminotomy surgery.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular screening (81161, 81238, 81404, 81407, 81408, 81411, 81413, 81414) provided on January 16, 2021.
You asked the Plan to pay for a hereditary cardiovascular screening. You say that the necessity of this testing is supported in the records. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular screening have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cardiovascular screening (81161, 81238, 81404, 81407, 81408, 81411, 81413, 81414) provided on January 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the parenteral nutrition solution provided from January 19, 2021 to January 23, 2021.

You asked the Plan to pay for the parenteral nutrition solution. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file shows that an itemized shipping/billing invoice to indicate the specific supplies rendered was not provided. In addition, proof of delivery was not provided for the billed dates of service. 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 parenteral nutrition solution provided from January 19, 2021 to January 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CPAP provided on February 28, 2021.
You asked the Plan to pay for the CPAP. You say that the enrollee does not have the original CPAP, that is why you gave him a new one. The Plan denied your request. The Plan says the enrollee's previous CPAP met the capped rental in April of 2018 and is still under reasonable useful lifetime of 5 years.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows the enrollee had a CPAP still under reasonable useful lifetime. There is no physician documentation supporting medical necessity for a new CPAP. Therefore, we decided that the Plan does not have to pay for the CPAP provided on February 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tacrolimus 0.1% ointment.
You asked the Plan to pre-approve the ointment. 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 Tacrolimus 0.1% ointment.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network providers.

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 a referral to an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewing radiographic images (D0274), a teeth cleaning (D1110), and topical application of fluoride (D1206) provided on April 20, 2021.
You asked the Plan to pay for a periodic oral evaluation, bitewing radiographic images, a teeth cleaning, and topical application of fluoride. You say that you were not aware that the provider was out-of-network. The Plan denied your request. The Plan says you are not covered for these services when seen by an out-of-network provider.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a periodic oral evaluation, bitewing radiographic images, a teeth cleaning, and topical application of fluoride have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewing radiographic images (D0274), a teeth cleaning (D1110), and topical application of fluoride (D1206) provided on April 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 8, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 drug testing services provided on December 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 1, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 drug testing services provided on December 1, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve continued use of a continuous glucose monitor for the enrollee.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says that a review of adherence to the monitor is a requirement.

The Plan must follow Medicare rules. Medicare rules say that every six months following the initial prescription of the monitor, the treating practitioner must have an in-person visit with the enrollee to assess adherence to the monitor. 

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 monitor. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee did not have his phone during the June 2021 visit, so the actual blood glucose data was not able to be reviewed. However, the enrollee was still seen that day to review the insulin regimen and overall diabetes care. Even though the data was not seen, the regimen and use of the monitor was reviewed. The criteria is met. 

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 monitor have been met. Therefore, we decided that the Plan has to pre-approve continued use of a continuous glucose monitor 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services provided on February 24, 2021.
You asked the Plan to pay for the services provided. You say that the services were ordered for the management of diabetes. The Plan denied your request. The Plan says one CPT code must be submitted for the panel.
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 looked at the file and the rules. We find that the services at issue were billed with multiple CPT codes. If a single procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the procedure. 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 testing services provided on February 24, 2021.