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

We decided that the Plan does not have to pre-approve chiropractic treatment.
You asked the Plan to pre-approve chiropractic treatment. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the records do not show any issues with the enrollee's spine.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 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 chiropractic treatment Our reviewer says that the enrollee does not meet the Medicare criteria for the requested chiropractic service. Our physician reviewer found there are no submitted imaging studies to reveal evidence of a subluxation. The submitted office visit notes reveal restricted motion, tenderness, and muscle spasms. These office visit notes do not reveal evidence of subluxation per Medicare guidelines. Therefore, this chiropractic treatment is not supported or allowed per Medicare guidelines. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of chiropractic treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic treatment.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits provided on May 31, 2019 to July 30, 2019 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for office visits. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 office visits provided on May 31, 2019 to July 30, 
2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve True Metrix Glucose Test Strips.
You asked the Plan to pre-approve the True Metrix Glucose Test Strips. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the item requested exceeds the normal dispensing limits.
The Plan follows Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 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 True Metrix Glucose Test Strips. Our reviewer says that the member has been instructed to check 4 times per day to help adjust the 4 shots per day regimen. Our physician reviewer found the requested strips should be provided to assist the member and their doctor in adjusting the insulin dose. 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 True Metrix Glucose Test Strips have not been met. Therefore, we decided that the Plan has to pre-approve True Metrix Glucose Test Strips.
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TENS device, two lead, localized stimulation 
(E0720X1). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the DME is medically necessary. 
 
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 DME. Our physician reviewer 
found the records do not meet criteria for TENS unit. The enrollee has not been enrolled in a comprehensive 
plan and the cause of back pain has not been clearly defined. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve TENS device, two lead, localized stimulation (E0720X1).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient mental health services provided by a licensed 
mental health clinician. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says neither Medicare nor your Medicare Advantage health plan will cover treatment by the 
requested provider type. 
 
Medicare rules say that plans can require enrollees to get care from certain providers. Medicare rules say that 
services must be provided by providers who are enrolled in the Medicare program. 
 
The rendering provider is not eligible to bill Medicare. The plan did not pre-approve the services. We found no 
exception that would require the plan to approve these items/services. Therefore, we decided that the Plan does 
not have to pre-approve outpatient mental health services provided by a licensed mental health clinician.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hospital bed, semi-electric (head and foot adjustment), 
with any type side rails, with mattress (E0260RR), for the enrollee. 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the Medicare rules have not been 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 the DME. Our physician reviewer 
found there was no indication that a fixed height or variable height manual hospital bed was warranted as there 
was no suggestion frequent or immediate adjustments were needed regularly. According to the notes, the 
patient is able to ambulate and would be able to adjust the bed. Based on the documentation provided, it 
appears that a hospital bed is warranted due to the patient's comorbidities, however, without sufficient support 
made for a semi-electric bed, this request for E0260RR will be considered 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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress 
(E0260RR), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records do not document an expectation of benefit and improvement 
from LTACH care. 
 
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 you do not require services at the proposed LTACH that are not already available at 
the current acute care hospital. Additional acute care services can be received at the current facility for now 
while ventilation attempts are completed. There are no services available at the proposed LTACH that you 
require that are not available and covered by the current facility. Therefore, this request for LTACH services 
will be considered not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long term acute care hospital (LTACH).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anesthesia. 
 
You asked the Plan to pre-approve the anesthesia. You say that the dental surgeon needs approval to perform 
the dental surgery before you develop more health problems from your bad teeth. The Plan denied your request. 
The Plan says there is no documentation of any underlying medical condition that would require the dental 
procedure to be done under anesthesia in the hospital or outpatient surgery setting. 
 
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. There is no documentation which shows that the dental services need to be provided in 
the inpatient setting. Therefore, we decided that the Plan does not have to pre-approve anesthesia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital visits provided from January 20, 2020 to January 23, 2020.
You asked the Plan to pay for the inpatient hospital visits. You say that the records support that this care was medically necessary. The Plan denied your request. The Plan says the enrollee had revoked hospice in January 2020. All services remain payable by the Original Medicare contractor until the end of that month.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on January 7, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the inpatient hospital visits provided from January 20, 2020 to January 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the continuation of acute care services is 
medically necessary. You also say that a LTACH admission is medically appropriate. The Plan denied your 
request. The Plan says the records do not support that the enrollee has completed their full course of care in the 
hospital. The Plan also says that it is not clear that the enrollee will need further complex hospital care for more 
than 25 days. 
 
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 that the enrollee does not require services at the proposed LTACH that are not 
already available at the current acute care hospital. Additional acute care services can be received at the current 
facility until stable for discharge to a lower level of care that, according to the notes, does not clearly appear to 
be needed for an additional 25 days. There are no services available at the proposed LTACH that the enrollee 
requires that are not available and covered by the current facility. Therefore, this request for LTACH services 
will be considered not medically necessary at this time. 
 
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 the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intermittent pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve the E0676 pneumatic compression device. You say that this enrollee is 
scheduled to undergo knee replacement surgery and it is felt by the surgeon that intermittent limb compression 
will be needed postoperatively. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
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, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pre-approve an intermittent pneumatic compression device (E0676).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (CPT 85025) provided to the enrollee on
December 5, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says blood count testing is not a covered service when used for screening purpose in asymptomatic
patients who do not have a condition expected to result in a hematological abnormality.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee is a 68 year old male with a diagnosed complete right rotator cuff tear or rupture (onset
11/27/2019). Surgical repair was recommended. No other medical history was listed in the records. A complete
blood count (CPT 85025) was ordered. Currently available evidence suggests that CBC is only warranted if a
patient is symptomatic or has a medical condition which would be expected to show an abnormality in the
blood count to justify a screening CBC. The notes provided did not show any symptoms or medical history
besides the rotator cuff tear, which is insufficient to justify a CBC at this time. Therefore, the CPT 85025 will
be considered not medically necessary based on the notes provided.
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 pay for laboratory services (CPT 85025) provided to the enrollee on December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on February 14, 2020.
You asked the Plan to waive the copayment for an office visit. You say that you received COVID-19 care and should not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for each visit with a primary care physician. The medical records show that you had an office visit provided on February 14, 2020. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit provided on February 14, 2020.
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 you would like reconsideration because the LTACH admission is medically necessary. The Plan denied your request. The Plan says the member is receiving appropriate care at the current facility. 
 
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 does not require services at the LTACH that are not already available at the current acute care hospital. The enrollee appears to be hemodialysis and ventilator-dependent without a need for management or weaning, a lower level of care with the ability to manage the ventilator-dependent status should be able to be arranged in less than 25 days. 
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.

You asked the Plan to pre-approve Prolia. You say that the enrollee has tolerated Prolia injections well. The Plan denied your request. The Plan says that this is not covered under Part B.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee. 

Benefits for Prolia 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Restasis Emu 0.05%. 
 
You asked the Plan to pre-approve Restasis Emu 0.05%. You say that the requested medication is necessary. 
The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a 
separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 
coverage. 
 
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 Restasis Emu 0.05%.  
 
Benefits for Restasis Emu 0.05% may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.