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

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond February 24, 2021.

You asked the Plan to pre-approve the continued SNF care. You say that you do not feel that you have progressed enough to be able to leave the facility. The Plan denied your request. The Plan says you are not able to benefit from daily skilled therapy due to non-weight bearing status, and the skilled nursing services are not needed on a daily basis.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 71-year-old female who was admitted to the SNF on 2/10 due to right foot osteomyelitis. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. She tolerated dialysis. She had wound care to her right foot and left heel. Regarding rehabilitation services, the beneficiary received physical and occupational therapy in the SNF. By the dates in question, the beneficiary was at a minimal assist level with functional mobility, and she remained non-weight bearing to her right leg.

There are no identifiable skilled therapy service needs. There are identifiable skilled nursing service needs; however, these services are not required on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond February 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance services provided to the enrollee on January 8, 2020.

You asked the Plan to pay for the air ambulance services. You say that these services were medically necessary. The Plan denied your request. The Plan says that the patient could have been safely transported by ground ambulance.

The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 

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 air ambulance services. Our reviewer says that the air ambulance services were not medically reasonable and necessary for the enrollee. The patient required ambulance services and alternative methods of transportation would not have been appropriate as she required oxygen and vitals monitoring. Ground transportation would not have posed a significant threat for this patient based on the documentation provided. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for the air ambulance 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 air ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the air ambulance services provided to the enrollee on January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic medial branch blocks (MBBs).

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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have chronic low back pain that increases with rotation and flexion. You refused physical therapy but are doing a home exercise program. The pain is rated at 3 out of 10. The records do not support that the criteria for coverage for the diagnostic MBBs are met; therefore, the services are 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 diagnostic medial branch blocks (MBBs).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a receiver for use with a therapeutic continuous glucose monitor system for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the rules require multiple insulin shots per day to cover this monitor. The enrollee is not taking insulin. The records do not show why a hand held meter would not be sufficient for blood glucose monitoring. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a receiver for use with a therapeutic continuous glucose monitor system for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Ilumya.

You asked the Plan to pre-approve Ilumya. You say that Ilumya has a vastly superior safety profile compared to other medications and is expected to provide the enrollee with significant clinical benefit. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Inflectra or Remicade and Stelara before it will approve Ilumya.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Ilumya. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Ilumya. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drugs of Inflectra or Remicade and Stelara. The documentation does not support that these drugs would likely be less effective and/or have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Ilumya.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on October 12, 2020.

You asked the Plan to pay for the dental services. You say that you were not aware that the services were not covered. You also say that the claim should be paid. The Plan denied your request. The Plan says complete series x-ray is not listed as 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 pay for the complete series x-ray (D0210) provided on October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on August 25, 2020.

You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment for this service is included in the cost of the primary procedure.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 95999 is not supported in the record. Specifically, train of four monitoring is considered integral to the primary neuromonitoring procedure and is not separately reimbursable. Based on this information, we decided that Medicare rules for coverage of the train of four monitoring have not been met. Therefore, we decided that the Plan does not have to pay for train of four monitoring (95999) provided on August 25, 2020.
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 enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. 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. The enrollee was admitted for acute respiratory failure and COVID pneumonia. Medical problems are stable. There are no complex nursing or rehabilitation needs. 

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 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: Unfavorable

We decided that the Plan does not have to pre-approve additional accessories for orthoses (L6600, L6635,
L2755, L5699).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this 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 the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the L2755 and L5699 are not medically necessary as these additions are specified for the lower extremity
and your approved orthosis was for the upper extremity. The L6600 and L6635 are for limb prosthesis which
you are not approved for. You are approved for an orthosis of the upper extremity. The requested items exceed
your medical needs and are therefore not 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 the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve additional accessories for orthoses (L6600, L6635, L2755, L5699).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve breast reduction.

You asked the Plan to pre-approve breast reduction. You say that you need this due to your breast cancer. The Plan denied your request. The Plan says that this is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that breast reduction is considered medically necessary to reduce the size of a normal breast to bring it into symmetry with a breast reconstructed after cancer surgery. Breast reconstruction of the affected and the contralateral unaffected breast following a medically necessary mastectomy is 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 breast reduction. Our reviewer says that the criteria for coverage of a breast reduction have been met in this case. Our physician reviewer found the enrollee will be undergoing a lumpectomy, or partial mastectomy, on the right, and breast reconstruction of both the affected and the contralateral unaffected breast following a medically necessary mastectomy is a covered procedure. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of breast reduction have been met. Therefore, we decided that the Plan has to pre-approve breast reduction.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says skilled services are not needed.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power wheelchair.

You asked the Plan to pre-approve the group 2 power wheelchair. You say that you would like reconsideration because this wheelchair is medically necessary. The Plan denied your request. The Plan says the clinical information does not indicate how you complete your daily activities or that there has been a home assessment.

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 group 2 power wheelchair. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the available medical records do not document that you have a mobility deficit that impairs your ability to participate in daily activities such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. Records do not include a home assessment or an assessment that you can safely operate the power wheelchair. 

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 group 2 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation (D4921 x 2) provided on November 4, 2020.

You asked the Plan to pay for the dental services. You say that the dental office did not contact your plan for approval for the services. You say that you are overwhelmed and annoyed that the provider office did not obtain approval in advance. You say that it is not fair that you have to pay for the services. The Plan denied your request. The Plan says gingival irrigation is not listed as 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 pay for the gingival irrigation (D4921 x 2) provided on November 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a segmental pneumatic appliance (E0667).

You asked the Plan to pre-approve a pneumatic compression device and a segmental pneumatic appliance. You say that the requested treatment is for scrotal swelling which is not treatable with a basic leg pump since it terminates at the thigh. The Plan denied your request. The Plan says rules for pre-approval have not been met.

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. Furthermore, E0667 is not separately payable when the base PCD is not covered. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a segmental pneumatic appliance (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (64999) provided August 28, 2020.

You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says the procedure was not coded correctly for payment.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 64999 is not supported in the medical record. Specifically, Medicare rules require that anesthesia providers bill anesthesia services with procedure codes 00100 - 01999. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (64999) provided August 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom 5 continuous glucose monitor (CGM).

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 therapeutic CGM 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 enrollee does not meet the criteria for coverage. Our physician reviewer found the enrollee has Type II diabetes and takes Levemir twice daily. She is only injection long-acting insulin twice daily, which does not require frequent intra-day dose changes. The criteria for coverage of the CGM are not met and the services are 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 Dexcom 5 continuous glucose monitor (CGM).