Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ensure.
You asked the Plan to pre-approve Ensure. You say that you have a medical condition and are unable to chew or eat solid foods. You say that you take nutritional drinks because they have the nutritional supplements that you need. You say that you drink Ensure 4 times each day and that you cannot afford to pay for this out of pocket. The Plan denied your request. The Plan says nutritional supplementation is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve Ensure
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) rendered by the out-of-network (OON) provider on March 11, 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 psychiatric diagnostic evaluation (90791) rendered by the out-of-network (OON) provider on March 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept, rural area, transport furnished by a
volunteer ambulance company (A0432), and the unspecified transportation service (A0999) provided on April
9, 2020.
You asked the Plan to pay for the transportation services. You say that you have been transported on several occasions to the emergency room by ambulance with the same paramedic. You say that you have never incurred any additional charges before. You say that the bill you received did not include any transport information. You also say that you feel you are not responsible for this charge. The Plan denied your request. The Plan says ambulance transportation is only covered when you are actually transported by ambulance. The Plan says that since you were not transported by this ambulance, the service is not covered. The Plan also says that there is no contract between the ALS (advanced life support) and BLS (basic life support) ambulance providers.
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS), the provision of medically necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services. The Plan has confirmed that the ALS paramedic intercept provider does not have a contract with the volunteer ambulance company that provided the transport services. Therefore, we decided that the Plan does not have to pay for the paramedic intercept, rural area, transport furnished by a volunteer ambulance company (A0432), and the unspecified transportation service (A0999) provided on April 9, 2020.
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) for the enrollee.
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 enrollee is receiving appropriate inpatient acute care, and does not require transfer to LTACH.
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 he 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. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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) for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT of the head or brain (70450) provided on September 12, 2020.
You asked the Plan to pay for the CT of the head or brain. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the CT of the head or brain (70450) provided on September 12, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PROLIA.
You asked the Plan to pre-approve PROLIA. You say that the drug is medically necessary. The Plan denied your request. The Plan says you have not tried or failed zoledronic acid and the prescriber has not explained why you cannot use zoledronic acid.
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 PROLIA. Our reviewer says that the drug is not medically necessary. Our physician reviewer found there is no documentation of trial and failure of Zoledronic acid or that it would likely be less effective and/or have adverse effects for you. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PROLIA have not been met. Therefore, we decided that the Plan does not have to pre-approve PROLIA.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional applications of Epifix skin substitute.
You asked the Plan to pre-approve 10 additional applications of Epifix skin substitute. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 10 additional applications of Epifix skin substitute. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case; the record indicates that you have received ten applications of the requested product since April 2021. During this time, the record indicates that the wound has not demonstrated significant clinical improvement. The requested service is not effective for you. 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 10 additional applications of Epifix skin substitute have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional applications of Epifix skin substitute.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (97530) provided on September 24, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not
supported.
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 97530 is "Therapeutic activities, direct (one-on-one)
patient contact (use of dynamic activities to improve functional performance), each 15 minutes".
We asked our coding 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 use
of code 97530 is not supported by the records provided. Our coding reviewer found that a HCPCS code is a
more appropriate code to report for services performed.
We looked at this coder'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 the services (97530) provided on September 24, 2020
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 13, 2021.
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 January 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from February 16, 2021, through February 20, 2021.
You asked the Plan to pay for the self-administered drugs. You say that these were necessary, and you need as much possible to be paid. The Plan denied your request. The Plan says self-administered drugs are not covered by Part B. The Plan also says that you will need to pay the bill and request reimbursement under your pharmacy 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 pay for the self-administered drugs provided from February 16, 2021, through February 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the periodontal maintenance (D4910)
or pay for the occlusal guard - hard appliance, full arch (D9944) received March 25, 2021.
You asked the Plan to pay an additional amount for the dental services. You say that the mouth guard protects
your teeth and helps with migraine headaches. The Plan denied your request. The Plan says there is no
coverage for occlusal guards and the correct cost share applied to the claim for the periodontal maintenance.
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 occlusal guard is not among those
covered under this benefit. The Plan agreed to cover the periodontal maintenance. Periodontal maintenance
requires 70% coinsurance. This service was billed at $50.
You were asked to pay $35 (70% coinsurance) and the Plan paid $15 for the periodontal maintenance.
Therefore, we decided that the Plan does not have to pay an additional amount for the periodontal maintenance
(D4910) or pay for the occlusal guard - hard appliance, full arch (D9944) received March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the fundus photography with interpretation and report (92250), the ophthalmological medical examination and evaluation (92014), and the eye refraction (92015) rendered by the out-of-network (OON) provider on February 4, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 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 fundus photography with interpretation and report (92250), the ophthalmological medical examination and evaluation (92014), and the eye refraction (92015) rendered by the out-of-network (OON) provider on February 4, 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 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
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program. The enrollee does 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. There is not a reasonable expectation that this enrollee 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CPAP replacement parts, cartridge filter kit (E1399) adapter (E1399) and hose assembly replacement (E1399) purchased February 28, 2021.
You asked the Plan to pay for CPAP replacement parts. You say that your CPAP machine has mold inside it. You could have requested a new machine. Instead, you chose to replace just the affected parts. The Plan denied your request. The Plan says the supplier is not a Medicare certified provider.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the CPAP replacement parts, cartridge filter kit (E1399) adapter (E1399) and hose assembly replacement (E1399) purchased February 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses provided to the enrollee on March 9, 2021.
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 according to the claims data available at the time of the review, the plan was unable to discover
any evidence of an established relationship between the enrollee and the ordering physician as required per
CMS guidelines.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that durable
medical equipment generally must be ordered by a physician who has furnished a consultation or treats an
enrollee for a specific medical problem.
The file does not contain documentation of an established relationship between the enrollee and the ordering
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of these
orthoses have not been met. Therefore, we decided that the Plan does not have to pay for orthoses provided to
the enrollee on March 9, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says until the clinical efficacy of this device can be established, it cannot be approved.
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the record indicates that the enrollee has lumbar spinal stenosis with neurogenic claudication. A lumbar
MRI from 2019 demonstrates severe spinal stenosis and foraminal narrowing. The elements of the coverage
criteria 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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.