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

We decided that the Plan does not have to pre-approve a lipectomy (15830).
You asked the Plan to pre-approve the lipectomy. You say that the procedure is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that lipectomy will only be considered reasonable and medically necessary when the procedure is performed due to another surgery being done at the same time and would effect the healing of the surgical incision. Lipectomy can also be covered following significant weight-loss following treatment of morbid obesity. 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 lipectomy. Our reviewer says that the procedure is not medically necessary. Our physician reviewer found the records do not indicate that a simultaneous procedure is being performed and the healing of such an incision would be impaired by not performing the lipectomy. The enrollee has not had weight surgery. The elements of the coverage rule are not satisfied based on the provided records.
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 lipectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve a lipectomy (15830).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the intravascular ultrasound (CPT code(s): 37252 and 37353), for the enrollee.
You asked the Plan to pay for the services. You say that the enrollee has persistent swelling, and the plan is to rule out May-Turner's Syndrome and/or other stenosis of the iliac veins. The Plan denied your request. The Plan says the codes are considered a bundled 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.
Your request does not meet the conditions for approval because the indicated codes are considered a bundled procedure and payment for it is included in payment for the already&#8208;approved additional codes. This service, intravascular ultrasound, is considered integral to the primary procedure and therefore is part of a bundled payment. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the intravascular ultrasound (CPT code(s): 37252 and 37353), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve healthy meals (S9977).

You asked the Plan to pre-approve the healthy meals. You say that you believe the healthy meals should be
covered for the enrollee. The Plan denied your request. The Plan says the enrollee did not have a qualifying
event determined by their provider.

Medicare does not cover this service; however, the Plan offers a supplemental Healthy Meals benefit which
exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these
services when the member has a qualifying event.

We looked at the file and rules. Based on this information, we decided that the Plan rules for coverage of the
Healthy Meals Benefit have not been met. Specifically, the record does not show that the member was in the
hospital and was discharged home, has a BMI less than or equal to 18.5 or equal to or greater than 25 or an
A1C level more than 9.0. Therefore, we decided that the Plan does not have to pre-approve healthy meals
(S9977).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services.

You asked the Plan to pre-approve inpatient psychiatric care. You say that inpatient psychiatric services are medically necessary. The Plan denied your request. The Plan says the enrollee does not require inpatient psychiatric services and can be treated in a less restricted setting.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric care.

Our reviewer says that the health Plan's denial of inpatient psychiatric services appears appropriate. Our physician reviewer found that based on a review of the provided records, it was not expected this enrollee would improve in a reasonable period of time, as they did not have dangerousness to self or others, auditory or visual hallucinations, delusions, and was not showing any aggressive behavioral issues. The enrollee was not going through withdrawals. It did not appear medically necessary and reasonable to have psychiatric/detoxification care provided at the acute inpatient level of care rather than a lower level of care as the enrollee did not have dangerousness to self or others, perceptual disturbance including auditory or visual hallucinations and was not going through any withdrawal symptoms. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis. Our physician reviewer was unable to find an individualized treatment plan; however, the entire record is not present. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided, the admission of this enrollee does not meet the criteria for acute inpatient mental health/detoxification treatment as this enrollee was not shown to be a danger to himself or others but was without agitation or aggression without perceptual disturbance including auditory or visual hallucinations and was not going through withdrawals.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to an LTACH is 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 requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.

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 LTACH services.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan.
You asked the Plan to pre-approve Hyalgan. The Plan denied your request. The Plan says the enrollee has not
tried and failed Orthovisc and Monovisc.
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 Hyalgan. Our physician reviewer found that The Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The enrollee has not tried and failed the required drugs. The plan's required drugs would not likely be less effective or likely 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 panel testing provided on January 11, 2021.
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing to determine if there was a more effective therapy for the enrollee's condition. The Plan denied your request. The Plan says this testing was not billed with the appropriate coding.
The Plan must follow Medicare rules. Medicare rules say that a genetic testing panel constitutes a single procedural service, so 1 procedure code must be submitted for this panel. We looked at the file and Medicare rules. This panel testing was billed with multiple procedure codes, which is not consistent with Medicare billing and coding rules for this testing. Based on this information, we decided
that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 panel testing provided on January 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that inpatient rehab will assist the enrollee to achieve
maximum functional capacity. The Plan denied your request. The Plan says the enrollee is unlikely able to
participate in an intensive therapy program 3 hours a day.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found
that the enrollee is at a moderate assist level for sitting up, minimal to moderate assist for standing, contact
guard assist for walking using a rolling walker, and moderate assist for lying down. The enrollee does not
require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen
hours per week of rehabilitative services and regular physician evaluation.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 24, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on January 24, 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 the requested admission to an IRF was medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF was 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 pay for IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs did not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee did not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee did require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent.
You asked the Plan to pre-approve Dupixent. You say that this request is medically necessary. The Plan denied your request. The Plan says this drug is not covered under your medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent.
Benefits for Dupixent 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on July 8, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the services provided to you by an out-of-network provider on July 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya.
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 step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has moderate to severe plaque psoriasis. She has not tried and failed the Plan's required drugs, Remicade or Inflectra and Stelara. The records do not show that the required drugs would be contraindicated or less effective; therefore, Ilumya is 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 Ilumya.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for a power wheelchair.
You asked the Plan to pre-approve the power seat elevation feature. You say that it is felt that this feature is medically necessary. The Plan denied your request. The Plan says this is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. Although this feature may be appropriate, neither Medicare nor the Plan covers this item. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (64494) provided on October 8, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE has been exceeded.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. 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 services (64494) provided on October 8, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on December 15, 2020 by an OON provider.

You asked the Plan to pay for the domiciliary or rest home visit. You say that the services were medically necessary. The Plan denied your request. The Plan says both the referring and rendering providers are non-participating with the enrollee's product for the date of service in question. The Plan also says that there is no authorization on file for the services in question.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit provided on December 15, 2020 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency transportation trips (A0120).
You asked the Plan to pre-approve additional non-emergency transportation trips. You say that the enrollee needs the additional trips to get to dialysis. The Plan denied your request. The Plan says the enrollee has utilized the maximum number of transportation trips allowed per year.
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. The Plan covers a maximum of 48 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional non-emergency transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on May 20, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the services provided to you by an out-of-network provider on May 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on May 21, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the services provided by an out-of-network provider on May 21, 2020.