Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the outpatient visit. You say that you would like reconsideration because you are not able to get an appointment with the in-network provider until January 2022. The Plan denied your request. The Plan says there are available appointments in August 2021 with an in-network provider who can render the necessary 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 the outpatient visit 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 an upper partial denture (D5213), and a lower partial denture (D5214).
You asked the Plan to pre-approve an upper partial denture, and a lower partial denture. You say that you lost your dentures and need new ones. The Plan denied your request. The Plan says the services are covered benefits, but you have exceeded the frequency limit of one every 5 Plan years.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an upper partial denture, and a lower partial denture have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on June 19, 2018. Therefore, we decided that the Plan does not have to pre-approve an upper partial denture (D5213), and a lower partial denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new scooter.

You asked the Plan to pre-approve the DME. You say that your scooter has been broken for five (5) months and your doctor sent the health plan a new authorization for DME and it was denied. The Plan denied your request. The Plan says a letter from your provider dated June 23, 2021, states that they spoke to the scooter provider. The Plan states the scooter provider told your doctor that you have a functioning scooter and thus they will not process your request for a second scooter because you are not eligible for a replacement at this time.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment (DME) have not been met.

Review of the records do not show that you need this scooter due to irreparable damage or loss of the other scooter purchased in 2020. In fact, your records show that you have a functional scooter. Under Medicare guidelines, your request is not a covered benefit because your records show that your scooter request is for a duplicate scooter and that you received a new scooter in April 2020. Therefore, we decided that the Plan does not have to pre-approve a new scooter.
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 based on review of the limited available records, you do not meet criteria for an IRF admission. There is no documentation of any nursing needs. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week. While you may benefit from physical therapy, 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. Your rehabilitation needs can be easily met at a less intense and alternate level of setting such as in a Skilled Nursing 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the documentation indicates that the enrollee has chronic low back pain and lumbar spinal stenosis. The record indicates that imaging has demonstrated multi-level disease including severe central stenosis at the L4-L5 level for which treatment is requested. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulatory blood pressure monitoring (93786) rendered by the out-of-network (OON) provider on March 16, 2021.
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 ambulatory blood pressure monitoring (93786) rendered by the out-of-network (OON) provider on March 16, 2021.
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 a major fall risk. The Plan denied your request. The Plan says you can be treated at a lower 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 you do not require treatment by multiple therapies and an intensive rehabilitation therapy program. While the documentation does support a need for physical or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Arformoterol.

You asked the Plan to pre-approve a tier exception. You say that you would like this approved. The Plan denied your request. The Plan says tier exceptions are only available for Part D drugs.

The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D drugs. 

The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for coverage of a tier exception have not been met. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Arformoterol.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular testing provided on September 18, 2020.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that the enrollee has a 90% carotid artery stenosis. The record indicates that the enrollee has no cardiac complaints and a normal cardiac physical examination. An unsupported diagnosis of ischemic cardiomyopathy is listed as a problem. The provided records do not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular testing provided on September 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation.

You asked the Plan to provide coverage for additional routine transportation. You say that additional transportation is medically necessary. The Plan denied your request. The Plan says once this benefit is exhausted it cannot be extended.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Once this supplemental benefit is exhausted, it cannot be extended or made exception to. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation.
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 would benefit from the level of care at an LTACH. The Plan denied your request. The Plan says the enrollee will not benefit from LTACH admission due to poor prognosis. There are no services available at the LTACH that are not being received 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 was admitted with acute on chronic respiratory failure. The enrollee has metastatic adenocarcinoma of the lung. The enrollee is ventilator dependent. 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 he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G Orthotic device (CPT code L8702), for the enrollee.

You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your request. The Plan says peer reviewed literature considers the use of robotic therapy for upper and lower extremity stroke rehabilitation investigational in nature and does not support its use since there is no long-term outcome data or continuation rate data at this time.

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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro orthosis is considered experimental, investigational and unproven when used to help restore function to arms and hands paralyzed or weakened by cerebrovascular accident (CVA) stroke, brachial plexus injury, cerebral palsy or any other neurological or neuromuscular disease or injury. There is insufficient literature in the peer reviewed publications to assess safety, efficacy, long term outcomes or patient management associated with the use of the MyoPro Orthosis for upper extremity paralysis/paresis. The review has determined that the items/services at issue in this case are not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G Orthotic device (CPT code L8702), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue (CPT code E2377), harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each (CPT code E2313) and electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (CPT code E2311).

You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the DME is not necessary.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The upgraded electronics (expandable controller, harness and electronic connector to 2 power options) are not medically necessary. They are necessary when there is a medical need to control power options though the joystick. The notes do not show a medical need to control the power options through the joystick. The power options can be controlled using their own switches. These switches can be made any size without asking for a separate request. They can be made from any material without asking for a separate request. All of this can be done without the need to use the joystick to control the power features. Therefore, we decided that the Plan does not have to pre-approve expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue (CPT code E2377), harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each (CPT code E2313) and electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (CPT code E2311).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on September 30, 2020.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. The Plan states a corrected claim would be accepted.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the Place of Service (POS) code is inconsistent with the services stated to have been provided. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on September 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extractions to be provided by an oral surgeon.

You asked the Plan to pre-approve the oral surgeon services. You say that you believe that these should be covered from an oral surgeon. The Plan denied your request. The Plan says only general dentist services are covered by your dental 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, this coverage is limited to the services of participating general dentists. Therefore, we decided that the Plan does not have to pre-approve dental extractions to be provided by an oral surgeon.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four occupational therapy home health visits (G0152).

You asked the Plan to pre-approve four occupational therapy home health visits. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not need skilled services.

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 four occupational therapy home health visits. Our reviewer says that the requested home health visits are not medically necessary. Our physician reviewer found the enrollee does not have documented skilled therapy needs. The enrollee's care needs are custodial. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of four occupational therapy home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve four occupational therapy home health visits (G0152).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Esophyx transoral incisionless fundoplication (TIF).

You asked the Plan to pre-approve the TIF procedure. You say that this procedure would benefit the enrollee by reducing GERD symptoms without invasive surgery. The Plan denied your request. The Plan says that there is not sufficient literature support for the clinical utility of this procedure.

The Plan follows Medicare rules. Medicare rules say that TIF may be covered with the limitations 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 the TIF procedure. Our reviewer says that the requested procedure is considered medically reasonable and necessary based on LCD guidelines. Our physician reviewer found the record indicates that the enrollee has gastroesophageal reflux. The enrollee has not had a prior Esophyx procedure. The record indicates that the enrollee's BMI is 28. The enrollee has a 2 cm hiatal hernia. The enrollee does not have grade B or greater esophagitis and there is no evidence of Barrett's esophagus. The elements of the coverage criteria are satisfied.

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 TIF procedure have been met. Therefore, we decided that the Plan has to pre-approve Esophyx transoral incisionless fundoplication (TIF).

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.