Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe two bone replacement grafts for ridge preservation provided September 16, 2019.You asked the Plan to pay forthe bone replacement grafts. You say that you were never informed by the Plan that this office was not covered.The Plan denied your request. The Plan says your EOC does not provide a benefit for this 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 forthe two bone replacement grafts for ridge preservation provided September 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand orthosis provided by Prescription Connection on July 30, 2019.
You asked the Plan to pay for the wrist hand orthosis (L3916). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says rules for telehealth services were not met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the wrist hand orthosis provided by Prescription Connection on July 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental alveoloplasty with extractions.
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 covered.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Your supplemental dental benefit is covered by the Medicaid portion of the Plan, not Medicare. Therefore, we decided that the Plan does not have to pre-approve dental alveoloplasty with extractions.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira for the enrollee.
You asked the Plan to pre-approve Humira. You say that Humira is medically necessary. The Plan denied your request. The Plan says Humira is not covered under Medicare Part B.
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 Humira for the enrollee.
Benefits for Humira 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standard manual wheelchair (K0001) and seat cushion (E2601).
You asked the Plan to pre-approve a standard manual wheelchair (K0001) and seat cushion (E2601). You say that the requested standard manual wheelchair and seat cushion are medically necessary. The Plan denied your request. The Plan says the requested standard manual wheelchair and seat cushion do not meet criteria.
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 standard manual wheelchair (K0001) and seat cushion (E2601). Our reviewer says that the requested standard manual wheelchair and seat cushion do not meet criteria. Our physician reviewer found the enrollee is diagnosed with abnormal gait and respiratory failure. A 12/26/19 therapy note indicates the enrollee owns a wheelchair. Therapy notes indicate the enrollee is ambulatory with a rolling walker. The occupational therapy notes dated 1/28/20 states that she performed all of her self-care tasks with supervision to contact guard assistance. Based on the documentation provided, the enrollee does not meet Medicare criteria for the requested standard manual wheelchair and seat cushion. The documentation does not reveal that the enrollee's mobility limitation significantly impairs her ability to participate in one or more mobility-related activities of daily living (MRADLs) in the home. The documentation on 12/26/19 indicates the enrollee has a wheelchair already. The documentation does not include a home evaluation indicating there is adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided. As the request for the standard manual wheelchair is not medically necessary the request for the seat cushion is also 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 a standard manual wheelchair (K0001) and seat cushion (E2601) have not been met. Therefore, we decided that the Plan does not have to pre-approve a standard manual wheelchair (K0001) and seat cushion (E2601).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the Genomic Sequence Analysis Panel provided on October 12, 2018.
You asked the Plan to pay for the panel. You say that your doctor ordered these tests, and should have obtained prior approval. The Plan denied your request. The Plan says that none of your providers ordered this test.
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. Medicare rules also say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan has not provided any medical records for review. Additionally, you say that this test was ordered by your doctor. Additionally, the file shows that the physician ordered these tests. This provider is participating with the plan. The file does not show that the plan provided notice that these services would not be covered. Therefore, you cannot be held responsible for these charges. Therefore, we decided that the Plan has to pay for the Genomic Sequence Analysis Panel provided on October 12, 2018.
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 pay for the physician services (99309) provided on August 5, 2019 by out of network provider.You asked the Plan to pay for the physician services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were out-of-network and were not emergent or preauthorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the physician services (99309) provided on August 5, 2019 by out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services (73630) on April 30, 2019
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were in-network providers who could render the services at issue.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the radiology services (73630) on April 30, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
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 services are not medically necessary. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH), having been admitted with infectious diarrhea. The enrollee subsequently developed a perforated ulcer, for which a surgical repair was performed. The enrollee required intubation/ventilation on February 4, 2020. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care (99291) and discharge day management (99239) provided from August 2, 2019 to August 5, 2019.
You asked the Plan to pay for critical care and discharge day management. You say that these services should be covered. The Plan denied your request. The Plan says the use of these codes is not supported by the medical record.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes and 99239 hospital discharge day management; more than 30 minutes. We find that CPT code 99291 and 99239 is not supported in the medical record. Specifically, these are time based codes. The submitted medical records do not contain documentation of the time spent on these services for the dates of service at issue. Based on this information, we decided that Medicare rules for coverage of critical care and discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for critical care (99291) and discharge day management (99239) provided from August 2, 2019 to August 5, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services for enrollee.You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee's needs are not skilled, and sufficient functional progress has not been made.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF services. Our physician reviewer found that the enrollee's current level of function is moderate/maximal assist with bed mobility, transferring with maximal assist, maximal assist with ambulating in the parallel bars, moderate to total assist with activities of daily living, and inconsistent participation with therapy. He has not made significant gains with therapy in the inpatient rehab facility. There are no noted daily skilled complex nursing needs. While the enrollee may benefit from continuing speech, physical and occupational therapy, the records do not support the need for daily therapy. His needs are custodial in nature.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approves killed nursing facility (SNF) services for enrollee.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance services provided on September 29, 2018.
You asked the Plan to pay for the ambulance services. You say that the transport was medically necessary and it was urgent that the enrollee get to the receiving facility to receive the specialty care needed. The Plan denied your request. The Plan says that non-emergent transports require prior authorization.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. We looked at the file and Medicare rules. The record shows the enrollee was in need of immediate neurology services not available in the Emergency Department. Based on this information, we decided that Medicare rules for coverage of the ambulance services have been met. Therefore, we decided that the Plan has to pay for the ambulance services provided on September 29, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided out of network from August 9, 2019 to September 25, 2019.
You asked the Plan to pay for out of network services. You say that you could not find an in-network chiropractor and this service should be covered. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
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 Plan contract also specifically states chiropractic care must be provided in network. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for chiropractic services provided out of network from August 9, 2019 to September 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea SNF admission and services for the enrollee.You asked the Plan to pre-approveSNF services. You say that the enrollee requires supervision for medication, therapy management, and assistance with activities of daily living.The Plan denied your request. The Plan says the enrollee is able to perform mobility related activities of daily living with very little assistance.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF services. Our physician reviewer found that the enrollee was admitted to the acute hospital for a second-stage revision of an infected right total knee arthroplasty. As of February 10, 2020, the enrollee was able to perform bed mobility independently and required standby assistance for transfers and when ambulating 250 feet. She had a slow cadence with step through gait pattern. She had knee range of motion from -3 to 86 degrees. The enrollee continues to receive wound care. She requires oversight of her medical conditions and medication management. The enrollee has not returnedto her prior level of function. The enrollee requires physical therapy for progression of her mobility at a community level. There are skilled needs, but they do not need to be provided on a daily basis. The enrollee is ambulating greater than household distances and performing essential activities of daily living without hands on assistance.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission and services for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan has to pre-approve Synvisc (J7325).
You asked the Plan to pre-approve Synvisc. You say that the medication is necessary. The Plan denied your
request. The Plan says that based on the documentation provided, coverage criteria for a step therapy exception
has not been met.
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 Synvisc. Our reviewer says that the
medication is medically necessary. Our physician reviewer found step therapy may only be applied to new
prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected
medication. The documentation supports that the enrollee in this case has actively received Synvisc-One.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Synvisc have been met. Therefore, we decided that the Plan has to pre-approve
Synvisc (J7325).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ankle-foot orthosis with stabilizer (L1971, L3170) provided to the enrollee on August 27, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for an ankle-foot orthosis with stabilizer (L1971, L3170) provided to the enrollee on August 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray, comprehensive oral evaluation, and prophylaxis provided on October 3, 2019.
You asked the Plan to pay for the panoramic x-ray, comprehensive oral evaluation, and prophylaxis. You say that prior to your appointment you contacted customer service and were recommended to go to this provider. The Plan denied your request. The Plan says this provider is out-of-network. The Plan also confirmed that you were not given any dentist's name during the conversation you had with customer 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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray, comprehensive oral evaluation, and prophylaxis provided on October 3, 2019.