Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy evaluation (CPT code 97161), for the enrollee.

You asked the Plan to pre-approve the service. You say that the enrollee underwent massive recurrent rotator cuff surgery. You state the enrollee continues to require physical therapy to focus on strength and range of motion. You state the enrollee's recovery has been delayed due to prolonged time prior to surgery and the compensation that occurred in their shoulder during that time and they require ongoing therapy to return to normal shoulder function and movements. The Plan denied your request. The Plan says the records show the enrollee is ready for discharge and they have achieved expected outcomes. The Plan states the test scores do not show the enrollee has made progress in their function with skilled treatment. The Plan states skilled treatment is not needed to maintain the enrollee's function and the enrollee (or their care giver) can manage the enrollee's condition with the home program they have learned. The Plan states more skilled treatment is not needed at this time.

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 service. Our physician reviewer found the physical therapy evaluation (CPT code 97161) is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had extensive prior therapy for their condition and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. The enrollee has been instructed in and is compliant in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve physical therapy evaluation (CPT code 97161), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided to the enrollee by an out-of-network provider.

You asked the Plan to pay for the office visit. 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 office visit provided to the enrollee by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller, expandable controller harness, electronic connection, power center mount articulating foot platform, privacy flap and attendant control.

You asked the Plan to pre-approve an expandable controller, expandable controller harness, electronic connection, power center mount articulating foot platform, privacy flap and attendant control. You say that these items are medically necessary. The Plan denied your request. The Plan says that these items are not necessary.

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 an expandable controller, expandable controller harness, electronic connection, power center mount articulating foot platform, privacy flap and attendant control. Our reviewer says that an expandable controller, expandable controller harness, electronic connection and power center mount articulating foot platform are not considered medically reasonable and necessary in this case. Records document that your upper extremity strength as 3+/5 bilaterally and your strength appears adequate to control the power options using their own switches which are included in the allowance for the power options. Our physician reviewer found that your condition does not meet criteria for coverage of an expandable controller, expandable controller harness, electronic connection and power center mount articulating foot platform.

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 expandable controller, expandable controller harness, electronic connection and power center mount articulating foot platform have not been met.

The rules say that for equipment to be covered, it must primarily serve a medical purpose. The privacy flap does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.

Medicare rules also say that if an attendant control is provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered. An attendant control cannot be covered in addition to the enrollee-operated device control system already included in the wheelchair approved by the plan.

Therefore, we decided that the Plan does not have to pre-approve an expandable controller, expandable controller harness, electronic connection, power center mount articulating foot platform, privacy flap and attendant control.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the fluoroscopic guidance services.

You asked the Plan to waive the copayments for the fluoroscopic guidance services. You say that the doctor only practices out of this facility, so the enrollee was forced to go there for knee injections. The Plan denied your request. The Plan says these copayments were charged correctly. The Plan also says that because the allowed amount for these services ($105.83) is less than the copayment obligation, the enrollee is responsible for the full allowed 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $110 copayment for radiological diagnostic services.

Records show that the enrollee had three knee injections using fluoroscopic guidance. The enrollee has been asked to pay a $110 copayment for each of the fluoroscopic guidance services. The fluoroscopic guidance services fall within the radiological diagnostic services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the fluoroscopic guidance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the urgent care visit provided an out of network (OON) provider.

You asked the Plan to pay for the urgent care visit. You say that you needed to use an out of network provider because the wait times at the available network providers was too long. The Plan denied your request. The Plan says criteria for obtaining out of network coverage were not met.

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 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 the urgent care visit provided by an out of network (OON) provider.

Your complaint about wait times with the available network providers is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Reblozyl.

You asked the Plan to pre-approve Reblozyl. You say that the medication is necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Reblozyl. Our reviewer says that the medication is medically necessary. Our physician reviewer found the review has determined that the documentation supports that the Reblozyl is medically reasonable and necessary for the enrollee. Given the minimal side effect profile of Luspatercept, the enrollee's prior treatment failures, and minimal treatment options for MDS, the documentation supports that the Reblozyl is safe and effective 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 Reblozyl have been met. Therefore, we decided that the Plan has to pre-approve Reblozyl.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown for tooth #15 (D2740).

You asked the Plan to pre-approve a crown for tooth #15. You say that the service is necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 a crown when the services are medically necessary and reasonable.

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 a crown for tooth #15. Our reviewer says that the service is not medically necessary. Our physician reviewer found a crown is present on the tooth at issue. X-rays do not show evidence of a cavity under the old crown. Replacement of the crown is not medically reasonable and necessary, as there is no documentation by the dentist of active decay in tooth #15.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a crown for tooth #15 have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown for tooth #15 (D2740).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ventolin.

You asked the Plan to pre-approve Ventolin. You say that the services are necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.

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 Ventolin.

Benefits for Ventolin 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee.

You asked the Plan to pay for this service. You say that skilled nursing facility services were medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not 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 pay for this service. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found Based on the documentation provided, it is my opinion that the enrollee no longer qualified for SNF coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. The enrollee was ambulating more than 100 feet and tending to daily activities with minimal supervision. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs were custodial and, as a practical matter, could 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 this service have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical notes provided show that the member continues to recover in your current hospital 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. The patient appears to be improving and requires only short-term additional acute care services that can be safely received in the current facility. The patient does not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.

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 for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve parathyroid imaging (78070).

You asked the Plan to pre-approve parathyroid imaging. 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 parathyroid imaging. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have a mildly elevated calcium. No further evaluation has been performed. No parathyroid hormone level determination has been performed. Imaging without further evaluation is not medically reasonable and necessary based upon the documentation provided. Therefore, the requested service is not 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 parathyroid imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve parathyroid imaging (78070).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the custodial care provided to the enrollee.

You asked the Plan to pay for the custodial care. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that custodial care is excluded from coverage.

We looked at the file and Medicare rules. The records show that the enrollee was provided custodial care during the dates of service in question. Custodial care is not covered by Medicare or the enrollee's plan. Therefore, we decided that the Plan does not have to pay for the custodial care provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.

You asked the Plan to pre-approve radiofrequency ablation. 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 radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental/ investigational due to the wide variation in efficacy reported in the literature. Therefore, the request is considered not medically reasonable or 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on September 1, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating 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 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 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 physician services provided on September 1, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D2950) you received on October 12, 2020.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says this is not a covered benefit.
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 requested services are not among those covered under this benefit. The Plan only covers those dental services for which the codes are listed in the Evidence of Coverage. Dental code D2950 is not listed, and therefore is not covered. Therefore, we decided that the Plan does not have to pay for the dental services (D2950) you received on October 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services you received on March 16, 2020, and March 20, 2020.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says out-of-network dental services are not covered.
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 requested services are not among those covered under this benefit when provided by an out-of-network provider. The records show that the requested services were provided by an out-of-network provider. The Plan contract clearly states that you must pay 100% of the cost of dental services received out-of-network. Therefore, we decided that the Plan does not have to pay for the dental services you received on March 16, 2020, and March 20, 2020.