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

We decided that the Plan does not have to pre-approve Synvsic.

You asked the Plan to pre-approve Synvisc. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requirements for coverage 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. Medicare rules also say that in order for viscosupplementation therapy to be covered, the clinical diagnosis must be supported by radiologic evidence of osteoarthritis of the knee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Synvisc. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 66-year-old male who is presenting with left knee pain with presumed osteoarthritis who has tried and failed intraarticular steroid injection, Tylenol, Ibuprofen, and home exercises.

A previous left X-ray on August 5, 2020, shows no acute osseus abnormality of the knee and no chronic articular abnormalities. Per communication with the provider's office, there are no current images of the knee. The review indicate that the clinical diagnosis is not supported by radiologic evidence of osteoarthritis of the knee. Also, the knee pain may be attributed to other forms of joint disease other than osteoarthritis since the X-ray does not support osteoarthritis. The enrollee does not have a qualifying indication per the LCD. Synvisc is not otherwise medically reasonable and necessary 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 Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvsic.
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 the treatment will be able to get you home faster because the treatment is better at inpatient rehab. The Plan denied your request. The Plan says the stay is 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 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for congestive heart failure. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy,
and an intensive rehabilitation therapy program. You do 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 you 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 IRF admission and services.
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 the enrollee requires IV antibiotics by intravenous methods until September 2, 2021. You say that the enrollee requires complex wound care to multiple wounds on the entire body. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that the enrollee's needs could be provided in another setting.
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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and two additional intraoral periapical x-rays provided on February 25, 2021.
You asked the Plan to pay for the intraoral periapical x-rays. You say that you would like to know if you are responsible for this bill. The Plan denied your request. The Plan says this service is covered once in a three year period. The Plan also says that benefits have been provided previously for a similar service within that time period. 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, periapical x-rays are limited to once every three years. The record shows that you received a first intraoral periapical x-ray on January 6, 2020 and your periapical x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray and two additional intraoral periapical x-rays provided on February 25, 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 admission to an IRF is necessary due to the enrollee's medical complexity and decrease in functional level. The Plan denied your request. The Plan says the enrollee does not have complex rehab needs that can only be met at an IRF. The enrollee can safely receive the necessary services in another setting.
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 that 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 require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. 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. 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: Imaging
Decision: Partially Favorable

We decided that the Plan has to pay for an electrocardiogram. We decided that the Plan does not have to pay for oral medication and a non-covered item or service.
You asked the Plan to pay for an electrocardiogram. You say that these services should be covered. The Plan says that these services are excluded from coverage.
We decided that the Plan has to pay for an electrocardiogram.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. An electrocardiogram is not a non-covered service. No information, Medicare rule citations, or medical records have been provided to show why this has been denied. Therefore, we decided that the Plan has to pay for an electrocardiogram.
We also decided that the Plan does not have to pay for oral medication and a non-covered item or service.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The rules also say that a status code of N indicates a non-covered service. The self-administered drugs billed with J8597 are not among the types which are covered by Medicare Part B. Code A9270 is used specifically to bill non-covered items or services and has a status code of N. Therefore, we decided that the Plan does not have to pay for oral medication and a non-covered item or service.
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 a group 3 power wheelchair.
You asked the Plan to pre-approve a group 3 power wheelchair. You say that the wheelchair she currently has continues to break down and she cannot go much of anywhere due to the ongoing issues. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the requested type of power wheelchair. The Plan says that the enrollee does not have a qualifying diagnosis causing mobility limitations for which the requested group 3 power wheelchair is medically needed.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity. The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to waive the cost sharing for the services you received on February 5, 2021.
You asked the Plan to waive the cost share. The Plan denied your request. The Plan says you are responsible for the deductible.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan does not say that there is a deductible you must meet before the Plan will pay its share of the case. The Plan says you must pay $130.23 for the services. Based on the Plan contract, however, you cannot be asked to pay more than $0 for the services. The Plan has asked to you to pay a cost share in the form of a deductible, however, the Plan contract does not indicate that you are responsible to meet a deductible. Additionally, the Plan contract says that Medicaid is responsible for covering your cost-sharing responsibilities. Therefore, we decided that the Plan has to waive the cost sharing for the services you received on February 5, 2021.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on May 28, 2020.

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 office visit (99213) rendered by the out-of-network (OON) provider on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation to be provided by an out-of-network provider.

You asked the Plan to pre-approve the consultation. You say that your condition is worsening and are a high-risk patient since you are experiencing dizziness with severe water retention. The Plan denied your request. The Plan says this is not an emergency and there are providers within your health plan network for a consultation with a Cardiologist.

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 the consultation to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) provided January 12, 2021.
You asked the Plan to pay for the upper partial denture. You say that you would like the dentures covered. The Plan denied your request. The Plan says you have exceeded frequency limits for this service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the upper partial denture once every 5 years. We looked at the file and Medicare rules. The Plan provided documentation that coverage for maxillary partial dentures was provided on November 14, 2018. Based on this information, we determined that the Plan's frequency limits for the upper partial denture have been exceeded. Therefore, we decided that the Plan does not
have to pay for the maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) provided January 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transportation (A0425, A0428) December 1, 2020.
You asked the Plan to pay for the ambulance transportation. You say that the services were medically necessary. The Plan denied your request. The Plan says the enrollee was an inpatient at the time the transport was provided and the ambulance service is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a hospital, it may be necessary to transport the beneficiary to another hospital or other site temporarily for specialized care while the beneficiary maintains inpatient status with the original provider. This movement of the patient is considered "patient transportation" and is covered as an inpatient hospital service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of ambulance transportation have not been met. Specifically, the record shows that the enrollee was admitted as inpatient to the origin location provider. The record also shows that the enrollee was moved to another provider while maintaining inpatient status with the original provider. This means that the ambulance service is covered as an inpatient hospital service and is not separately billable. Therefore, we decided that the Plan does not have to pay for ambulance transportation (A0425, A0428) December 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nonstandard seat frame width (CPT code E2340), heavy duty wheelchair, fixed full length arms, elevating legrest (CPT code E1295), arm rest (CPT code E0994) and positioning belt/safety belt/pelvic strap (CPT code E0978).

You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your request. The Plan says the items are not covered.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the items have not been met. Medicare rules say that seat belt, armrests, frame and height are already included with the approved wheelchair and cannot be covered separately. Therefore, we decided that the Plan does not have to pre-approve nonstandard seat frame width (CPT code E2340), heavy duty wheelchair, fixed full length arms, elevating legrest (CPT code E1295), arm rest (CPT code E0994) and positioning belt/safety belt/pelvic strap (CPT code E0978).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation from a physician's office provided on September 1, 2020.
You asked the Plan to pay for the ambulance transportation. You say that it is felt that this is a covered service since physician visits must be covered per COVID guidance. The Plan denied your request. The Plan says ambulance transportation is only covered when medically necessary which was not proven in this case.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. We 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 ambulance transportation. Our reviewer says that the criteria for coverage of the ambulance trip have not been met in this case. Our physician reviewer found the patient is a 79-year-old male who had a cystoscopy procedure in the medical office He was transported from the medical office via ambulance to another facility (scheduled, nonemergent). Vitals were stable and there were no complications documented related to the procedure.
The member did not have presenting symptoms that meet prudent layperson criteria for emergency care. The documentation does not show that other means of transportation such as a stretcher van would be contraindicated for this patient. The patient's vital signs were stable, and he did not require oxygen, special equipment, or expertise to provide safe transport on 9/1/20. 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 ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation from a physician's office provided on September 1, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the enrollee needs therapy. The Plan denied your request. The Plan says the records they have say the enrollee went to the hospital because of problems care for themselves. The Plan state they do not see that the enrollee needs more physical therapy, they do not need more care for complex needs, they need complicated wound care and the enrollee can have the care they need at home, with help.

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 qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.