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

We decided that the Plan does not have to pre-approve the LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for the requested LTACH services are not met.

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 that the enrollee was admitted due to bleeding around a feeding tube. In this case, acute hospital stay has not been denied. The enrollee is currently receiving necessary services. An LTACH facility is an acute care facility. There are no services the enrollee requires that cannot be received at the current facility. The elements of the coverage rule are not satisfied. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve the LTACH services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on November 6, 2020 by an out of network (OON) provider.

You asked the Plan to pay for lab tests. You say that you were not aware of the prior authorization requirement. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

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 laboratory testing provided on November 6, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an office visit provided by an out-of-network provider.

You asked the Plan to pre-approve an office visit. You say that you would like these services approved. The Plan denied your request. The Plan says that there are in-network providers available.

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 has failed to provide a 2021 Evidence of Coverage. Therefore, we decided that the Plan has to pre-approve an office visit provided by an out-of-network provider.

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 pay for three resin-based composites (fillings) (D2331, D2391) to be provided by your long-time dental provider.

You asked the Plan to pay for the fillings. You say that you have seen your current dentist for over 20 years and trust this provider. You did not realize when you signed up that this benefit option would require you to see a different specified dental provider. The Plan denied your request. The Plan says dental services under your supplemental plan will only be covered when they are provided by the dentist you were assigned upon enrollment. The only exceptions are a plan-directed specialist when medically necessary and emergencies.

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, services must be received from the Plan-assigned provider in order to be covered under this benefit. Therefore, we decided that the Plan does not have to pay for three resin-based composites (fillings) (D2331, D2391) to be provided by your long-time dental provider.

Your complaint about a possible misunderstanding and whether or not you have other options for dental coverage 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided from July 06, 2019 through
July 10, 2019 with the reported secondary diagnosis code E44.1.

You asked the Plan to pay for inpatient hospital services provided from July 06, 2019 through July 10, 2019 with the reported secondary diagnosis code E44.1. The Plan denied your request. The Plan says while etiologic criteria was met with this patient who has a diagnosis of breast cancer; there was no documentation of altered body composition or biological function.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. 

In this case, you billed the inpatient services provided with secondary diagnosis, E44.1 Mild Protein-Calorie Malnutrition. 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 DRG 584 for inpatient hospital services provided from July 06, 2019 through July 10, 2019. Our reviewer says that the documentation does not support that the inpatient care is payable as billed.

Our physician reviewer found that the enrollee presented to the facility for treatment of a right breast abscess. The provider noted that GLIM criteria is satisfied as the enrollee had breast cancer/radiation with 1-2 kg weight loss. However, the physician documented that "The patient has not had weight loss." Although GLIM does not outline specific phenotypic criteria for mild malnutrition, according to GLIM consensus criteria, malnutrition is diagnosed based on the presence of a significant etiology, and phenotypic criteria, such as, the degree of measured involuntary weight loss, body mass index, or reduced muscle mass. While etiologic criteria were met with this enrollee who has a diagnosis of breast cancer; there was no documentation of altered body composition or biological function. The review has determined that the secondary diagnosis, E44.1 Mild Protein-Calorie Malnutrition, was not supported by the medical records. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay the inpatient services provided from July 06, 2019 through July 10, 2019 with the reported secondary diagnosis code E44.1.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required and preventive procedure provided on December 8, 2020.

You asked the Plan to pay for the core buildup and preventive procedure. You say that you believe these services should be covered. The Plan denied your request. The Plan says these services are not covered. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.

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 pay for the core buildup, including any pins when required and preventive procedure provided on December 8, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.

You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says the enrollee has not tried and failed Retacrit.

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 Aranesp. Our physician reviewer found that the enrollee has a history of anemia secondary to chronic kidney disease. The Plan requires a trial of Retacrit before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug. There is no documentation provided indicating that the plan's required drug would likely be less effective 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 Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan of the chest (CPT 71250) for the enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says the correct test was not requested.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found a standard diagnostic chest CT scan is not medically necessary. The enrollee is a current smoker, and meets the criteria for an annual low-dose chest CT for lung cancer screening. That was the intended test, according to the clinical note of 11/10/2020. 

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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan of the chest (CPT 71250) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that since your stroke it's difficult to get out of bed to go to the bathroom. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of Vertiflex Superion device (22869, 22870).

You asked the Plan to pre-approve the Vertiflex device. You say that you highly recommend this minimally invasive procedure when conservative treatment has failed and as a safer alternative to a laminectomy or spinal fusion procedure. The Plan denied your request. The Plan says there are not enough studies on Vertiflex Superion to show it is safe and effective to treat back pain.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of Vertiflex Superion device (22869, 22870).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Clonazepam for the enrollee.

You asked the Plan to pre-approve this drug. You say that the enrollee is stable on this medication. The Plan denied your request. The Plan says that this is not covered under Part B.

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 Clonazepam for the enrollee.

Benefits for this drug 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana 15 mcg/2 ml solution for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says a step therapy exception cannot be granted.

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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found in this case, the record indicates that the enrollee has not tried and failed or had an adverse reaction to the plan's preferred drug, Perforomist. The requested drug is a new prescription. The elements of the coverage rules are not satisfied. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Brovana 15 mcg/2 ml solution for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prednisone for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.

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 Prednisone for the enrollee.

Benefits for this drug 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodontal scaling and root planning (D4341) for the lower left and lower right quadrants.

You asked the Plan to pay for the scalings and planings. You say that [Enter appellant's argument from appeal letter, e.g. "...you need SNF care."] The Plan denied your request. The Plan says this service is limited to 1 time every 3 years. The Plan also says that the enrollee has already received this service during that time.

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, periodontal scaling and root planning and is limited to one of either codes D4341 or D4342 once per quadrant per 3 calendar years. The record shows that the enrollee received a periodontal scaling and root planning of one to three teeth per quadrant (D4342) on lower right quadrant on January 21, 2020, and a periodontal scaling and root planning of one to three teeth per quadrant (D4342) on the lower left quadrant on January 23, 2020, and the enrollee's periodontal scaling and root planning benefits for the lower left and lower right quadrants have been exhausted. Therefore, we decided that the Plan does not have to pay for a periodontal scaling and root planning (D4341) for the lower left and lower right quadrants.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Injectafer (J1439).

You asked the Plan to pre-approve Injectafer. You say that Injectafer is medically necessary. The Plan denied your request. The Plan says a trial of oral iron supplementation is required before Injectafer can be considered.

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 Injectafer. Our reviewer says that Injectafer is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drug or any reason why the plan preferred drug would be unsafe or ineffective for 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 injectafer have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer (J1439).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for BLS emergency ambulance services (A0429) provided July 1, 2020.

You asked the Plan to pay for the ambulance service. You say that the reason for the appeal is that the reason given for denial, as stated on the notice, is incorrect as evidenced by data in the discharge summary and the timeline of events provided. The Plan denied your request. The Plan says the transport received does not meet the criteria.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code A0429 is BLS emergency ambulance transport. 

We find that CPT code A0429 is not supported in the medical records. Specifically, the provider has billed with the incorrect CPT code that indicates an ambulance transport and should have billed the CPT code for ambulance response, treatment no transport. Based on this information, the Medicare rules for coverage of CPT code A0429 have not been met. Therefore, we decided that the Plan does not have to pay for BLS emergency ambulance services (A0429) provided July 1, 2020.
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 a skilled nursing facility is not appropriate due to the complexity of his care needs. The Plan denied your request. The Plan says the enrollee still has acute care needs.
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 physician reviewer found that the enrollee was admitted to the acute care hospital for hemorrhagic shock and blood loss anemia. His hospitalization was complicated by acute hypoxic respiratory failure. He still has acute care needs. He is receiving appropriate care at the present acute care hospital. He does not require services at the LTACH that are not available at the acute care hospital where he/she is currently receiving care. Therefore, the requested LTACH services are not medically 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mobility scooter.
You asked the Plan to pre-approve a mobility scooter. You say that the requested item is a medical necessity for you The Plan denied your request. The Plan says rules for a mobility scooter have not been met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The case record does not have sufficient documentation to show that you have a mobility deficit that impairs your participation in MRADLs, that your condition cannot be improved by a walker, cane, or manual wheelchair, or that you can safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a mobility scooter.