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

We decided that the Plan does not have to pre-approve an oxygen concentrator E1390.
You asked the Plan to pre-approve an oxygen concentrator E1390. You say that you need the an oxygen concentrator. The Plan denied your request. The Plan says criteria is not met for an oxygen concentrator E1390.
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for patients with significant hypoxemia who meet certain blood gas evidence requirements. In addition, the patient must have tried other alternative treatments without complete success.
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 an oxygen concentrator E1390. Our physician reviewer found coverage criteria for home oxygen supplementation are not met. To qualify for oxygen, the saturation must be 88% or less for at least 5 minutes during the night. According to the overnight oximetry report, this enrollee was below 88% for only 2.2 minutes. Therefore oxygen supplementation is not medically necessary, and the denial is upheld. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an oxygen concentrator E1390 have not been met. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator E1390.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dry needling (CPT 20561).
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that items and dry needling is not a covered service.
This is not a covered benefit. Based on this information, we decided that Medicare rules for coverage of the
therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve dry needling
(CPT 20561).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee cannot care for herself. The Plan denied your request. The Plan says the notes do not show a need for close care from a rehab physician.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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's current level of function is at moderate assist for ambulation using a rolling walker, moderate assist for bed mobility, and moderate assist for transfers. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that her medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional physical and occupational therapy, but does not require this on an intensive rehabilitation facility therapy program level 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 for the enrollee.
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 above.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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, the member is mostly MAXIMUM/TOTAL assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy may be more appropriate. It is not clear the member would be able to fully benefit and/or participate in an IRF 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 foot orthotics.You asked the Plan to pre-approve foot orthotics. You say that your doctor only said you needed inserts, and not a brace.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided onSeptember 23, 2019.You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment.The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $90 copayment up to a maximum for emergency care. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows you received services during your emergency room visit.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 the emergency room visit provided on September 23, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio for the enrollee.
You asked the Plan to pre-approve Entyvio. You say that this is medically necessary. The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception.
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 Entyvio. Our reviewer says that Entyvio is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed Remicade or Inflectra; and Stelara or that they would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Entyvio. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the DecisionDX Melanoma test provided on October 1, 2019
by the out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that the testing was confirmed to be covered by
Medicare. You say that the enrollee was referred by their treating physician with the intent to use the results to
determine treatment. The Plan denied your request. The Plan says prior authorization was not obtained for the
services that were rendered to the enrollee. The Plan also says the services were not urgent or emergent in
nature.
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 DecisionDX Melanoma test provided on
October 1, 2019 by the out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that you require the stocknigs to aid with swelling in your arm that has occurred since having lymph nodes removed. The Plan denied your request. The Plan says the stockings do not meet the statutory definition of a dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora ThermoSpa hot tub and installation supplies (E1399) (99070).You asked the Plan to pay for the ThermoSpa hot tub and installation supplies. You say that you need this item.The Plan denied your request. The Plan says this is not a covered benefit.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue does not meet Medicare's definition of DME.  While a moving water bath may be helpful to treat your medical condition, the purpose of a retail hot tub is not primarily to treat a medical condition and would be useful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay fora ThermoSpa hot tub and installation supplies (E1399) (99070).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compressor (E0650) and segmental gradient pressure pneumatic appliances, half leg (E0673).You asked the Plan to pay for intermittent limb compression device and appliances. You say that the claim should be paid.The Plan denied your request. The Plan says pneumatic compression devices are only approved for lymphedema and chronic venous insufficiency with ulcers.The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.The file does not show that enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers.Therefore, we decided that the Plan does not have to pay for a pneumatic compressor (E0650) and segmental gradient pressure pneumatic appliances, half leg (E0673).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for local anesthesia (D9210) prophylaxis (D1110) periodic oral exam (D0120) provided on July 15, 2019.
You asked the Plan to pay for the dental services. You say that you would like to appeal the denial and feel the receptionist made an error as it was only 13 days before the 6 month period. The Plan denied your request. The Plan says anesthesia is not a covered benefit. The oral exam and cleaning is covered once every 6 months and this request exceeds the benefit limit.
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 local anesthesia is not among those covered under this benefit. Records show that you received an oral exam and cleaning on January 28, 2019. This benefit would not have been available until after July 28, 2019. Therefore, we decided that the Plan does not have to pay for local anesthesia (D9210) prophylaxis (D1110) periodic oral exam (D0120) provided on July 15, 2019.
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. The Plan denied your request. The Plan says that they did not receive documentation with information meeting these criteria.
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 Prolia is not medically reasonable and necessary for the enrollee in this case. The enrollee has a diagnosis of Other specified disorders of bone density and structure, unspecified site. The clinical records in the case file list a diagnosis of osteopenia, with no documentation of an osteoporotic fracture. The documentation does not support that the enrollee has tried and failed Zoledronic acid or that it would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Prolia. 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Otezla for the enrollee.
You asked the Plan to pre-approve Otezla. You say that the enrollee has tried and failed high dose topical
steroids. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B drugs.
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 Otezla for the enrollee.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Meals on Wheels deliveries.
You asked the Plan to pre-approve the Meals on Wheels services. You say that you require healthy food for
your condition and are not able to do this yourself. The Plan denied your request. The Plan says this is not a
covered benefit under Medicare or as a supplemental benefit offered by your plan.
The Plan must follow Medicare rules. Medicare rules say that meal preparation and meal delivery services are
considered custodial care which is excluded from Medicare coverage. Therefore, we decided that the Plan does
not have to pre-approve Meals on Wheels deliveries.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug therapy services provided to the enrollee on May 16, 2019 and billed under codes G0483, 80157, 80177, 80201, 80162, 80159, 80173 and 80307.You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) G0483 (1 Unit) and Current Procedural Terminology (CPT) code 80307 (1 Unit) remain not supported. The documentation submitted did not include a physician order/lab requisition for the billed test. The Plan also states that codes 80157, 80177, 80201, 80162, 80159, and 80173 cannot be paid because the specimen type collected is incorrect for the billed code; therefore, the code cannot be verified. The submitted toxicology request form indicates the specimen was urine. It is noted multiple attempts were made to obtain additional information from the provider.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 claim submitted did not contain a valid physician order. In addition, the specimen type collected was not coded correctly. Therefore, we decided that the Plan does not have to pay for drug therapy services provided to the enrollee on May 16, 2019 and billed under codes G0483, 80157, 80177, 80201, 80162, 80159, 80173 and 80307.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultraviolet light therapy system (E0691).
You asked the Plan to pay for the ultraviolet light therapy system. You say that the claim should be paid. The Plan denied your request. The Plan says the encounter appears to be a Telehealth service encounter however Telehealth guidelines have not been 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 an ultraviolet light therapy system (E0691).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve podiatry services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvepodiatry services. You say that you would like a referral for this podiatrist The Plan denied your request. The Plan says the enrollee is approved to see provider, other provider or other provider. 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve podiatry services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve evaluation and pain management to be provided by an out of network (OON) provider.You asked the Plan to pre-approve evaluation and pain management. You say that you would like this claim approved for out-of-network services.The Plan denied your request. The Plan says you can see doctor or Doctor for post-polio syndrome. The Plan says that you can see doctor or provider for pain management.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve evaluation and pain management to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says services that can only be received in a SNF are not medically needed.
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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the review has determined that there is no documentation provided indicating that this enrollee requires skilled nursing services, i.e., are the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not require skilled therapy services, i.e., are the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment. There is no documentation that the requested skilled services are required and medically reasonable and necessary to be provided on a "daily basis".