Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration because the LTACH admission is medically necessary. The Plan denied your request. The Plan says the notes do not show that the member needs complex medical care that has to be done at this intense level of care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found 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. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex surgery.

You asked the Plan to pre-approve Vertiflex surgery. You say that this surgery is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex surgery is not medically necessary and reasonable.

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 Vertiflex surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device before coverage will be approved. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup (D2950), and a crown (D2740).
You asked the Plan to pre-approve a core buildup, and a crown. You say that you want the Plan to pay for these services. The Plan denied your request. The Plan says the services at issue are not covered benefits.
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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a core buildup (D2950), and a crown (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided December 18, 2020.

You asked the Plan to pay for the limited oral exam and tooth extraction. You say that you were unaware this provider did not accept Medicare and believe the Plan should cover a portion of the bill. The Plan denied your request. The Plan says since your provider has opted out of Medicare, the Plan does not cover the service.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

We looked at the file and Medicare rules. In this case the provider who rendered the services has opted out of Medicare. Based on this information, we decided that the Plan's rules for coverage of the limited oral exam and tooth extraction have not been met. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided December 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for structural bodywork massage services provided on January 1, 2020.

You asked the Plan to pay for the massage services. You say that you only requested partial reimbursement because you knew that you had used part of the allowance for this benefit already. You feel it should be covered because you know someone else with this plan who received reimbursement for a Structural Bodywork service. The Plan denied your request. The Plan says massage services are not covered under the wellness allowance benefit.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $300 towards the cost of certain services under this benefit. Services include membership in a qualified health club or fitness facility, instructional fitness classes, participation in some wellness programs, nutritional counseling and acupuncture.

The Plan's rules for coverage of gym benefits have not been met because massage services or structural bodywork are not listed as covered services under this benefit. Therefore, we decided that the Plan does not have to pay for structural bodywork massage services provided on January 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit to treat a toothache (99203) provided February 9, 2021.

You asked the Plan to pay for the office visit to treat a toothache. You say that the service was medically necessary. The Plan denied your request. The Plan says this type of service is excluded by your plan.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the office visit to treat a toothache (99203) provided February 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiation therapy for right breast cancer.

You asked the Plan to pre-approve the radiation therapy for breast cancer. You say that you would like reconsideration because this service is urgent and medically necessary.The Plan denied your request. The Plan says there is no current research showing that the members type of cancer responds better to the requested type of treatment than the type that can be approved by the Plan.

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 radiation therapy for breast cancer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the case file does not provide a plausible rationale for the need of proton therapy over conventional radiation and/or IMRT in this patient. Furthermore, the LCD does not include right sided breast cancer as a Group 1 or Group 2 indication.

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 radiation therapy for breast cancer have not been met.Therefore, we decided that the Plan does not have to pre-approve radiation therapy for right breast cancer.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the type of PET scan requested.
You asked the Plan to provide coverage for a PET scan. You say that a PET scan is medically necessary. The Plan denied your request. The Plan says the specific PET scan requested is not covered for initial treatment. The Plan states that this type of scan is only approved for recurrent prostate cancer. We overturned the Plan's denial. The Plan requested a reopen and stated that we did not apply the correct coverage criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. The Medicare NCD 220.6.17 states that this type of PET scan is not covered for the evaluation of prostate cancer for initial treatment strategy. Therefore, we decided that the Plan does not have to provide coverage for a whole-body positron emission tomography (PET) scan using Axumin (Fluciclovine F-18, code A9588).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMS device (CPT code(s): 33289 and C2624), for the enrollee.

You asked the Plan to pre-approve the CardioMEMS device. You say that over the last year the enrollee's symptoms have worsened, and the enrollee has been on the edge of hospitalization many times. You state the CardioMEMS device will allow the doctor to better manage the enrollee's symptoms that lead to heart failure. The Plan denied your request. The Plan says that the enrollee is not enrolled in a clinical trial and there is no information regarding the size of the pulmonary artery diameter for appropriate localization of this device.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CardioMEMS device. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found given the severe symptoms of recurrent congestive heart failure (CHF) which appears very sensitive to volume loading conditions, the complexity of the medical regimen and the failure to prevent acute CHF hospitalization in this enrollee, use of the CardioMEMS device is reasonable and has clinical data, expert opinion, and approved Food and Drug Administration (FDA) indications to back up its use in selected appropriate clinical situations like this one. Although the pulmonary artery size is not reported, the operators would assess this either prior to or during implantation to make sure the device is clinically and technically appropriate. This device would therefore meet the medical reasonableness and necessity criteria of the applicable CMS Section 1862(a) 1(A) rule.

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 CardioMEMS device have been met. Therefore, we decided that the Plan has to pre-approve the CardioMEMS device (CPT code(s): 33289 and C2624), for the enrollee.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve the SNF admission. You say that the enrollee is strong willed. You say that he understands that he needs therapy to get better. You also say that the enrollee would benefit from therapy. The Plan denied your request. The Plan says the enrollee would not benefit from skilled services at this time. The Plan says that the enrollee would not be able to meaningfully participate in therapy due to being non-weight bearing at this time. The Plan also says that the requested services are not medically necessary.

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 the SNF admission. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.

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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more (CPT code K0864), for the enrollee.

You asked the Plan to pre-approve the wheelchair. You say that the wheelchair is necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.

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 wheelchair have not been met. For a K0864 Power wheelchair, extra heavy duty, weight greater than 570 pounds is not medically necessary because the enrollee's doctor has not stated the enrollee's current weight and they have no documentation that the enrollee's residence is suitable for the safe operation of this device. Therefore, we decided that the Plan does not have to pre-approve power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more (CPT code K0864), for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Hyalgan/Supartz injection (J7321).
You asked the Plan to pre-approve this medication. You say that this medication is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee has not met the required Step therapy criteria for coverage of this medication.
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 this medication. Our reviewer says that the enrollee does not meet the step therapy criteria required for coverage of this medication. Our physician reviewer found that the Plan requires a trial of drug Durolane and Synvisc/Synvisc-One before they will approve the requested drug. In this case, the patient has not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects 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 this medication have not been met. Therefore, we decided that the Plan does not have to pre-approve the Hyalgan/Supartz injection (J7321).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on October 20, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.

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 to you by an out-of-network provider on October 20, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMS HF system for the enrollee.

You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says that there is not enough medical proof to show the safety and/or success for heart failure monitoring.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the system. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has severe heart failure/diastolic dysfunction and is on multiple congestive heart failure (CHF) medications with recent hospitalization for CHF. He does not readily tolerate ACE/ARB therapy as well. Management of his heart failure with standard medical therapy and relying on symptoms and signs has not been effective in keeping him with minimal symptoms and has resulted in acute hospitalization and development of cardio-renal syndrome. CardioMEMS device monitoring in this situation can provide additional heart filling pressure data to better manage very complex diuretic and vasodilator regimens to more meticulously manage his fluid status to prevent either fluid overload or renal failure from over-diuresis (which has been an ongoing issue in this 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 the system have been met. Therefore, we decided that the Plan has to pre-approve the CardioMEMS HF system for the enrollee.

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 rendered on January 13, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the proper POS code. We looked at the file and Medicare rules. The file shows that procedure code 99214 (office visit) was incorrectly billed with Place of Service (POS) code 12 for a home visit. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the office visit rendered on January 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan has to waive the coinsurance for radiation therapy services provided on November 16, 2020, December 2, 2020, December 7, 2020 and December 9, 2020. We also decided that the Plan does not have to waive the coinsurance for radiation therapy services provided on December 11, 2020 and December 14, 2020.

You asked the Plan to waive the coinsurance for radiation therapy services and office visit. You say that you believed there wouldn't be any significant out-of-pocket expenses. You say that the charges seem excessive. The Plan says that the coinsurance applied correctly.

We decided that the Plan has to waive the coinsurance for radiation therapy services provided on November 16, 2020, December 2, 2020, December 7, 2020 and December 9, 2020.

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. The Plan did not submit complete claim screens or explanation of benefits showing the coinsurance applied for these dates of service. This means that we cannot determine the coinsurance amounts you are being asked to pay for these dates are correct or justified by the Plan contract. Therefore, we decided that the Plan has to waive the coinsurance for radiation therapy services provided on November 16, 2020, December 2, 2020, December 7, 2020 and December 9, 2020.

We also decided that the Plan does not have to waive the coinsurance for radiation therapy services provided on December 11, 2020 and December 14, 2020.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as co-payments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for radiation therapy services.

TOTAL:
$97.66

Therefore, we decided that the Plan does not have to waive the coinsurance for radiation therapy services.

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.