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

We decided that the Plan does not have to pre-approve a myoelectric prosthesis for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that is not covered.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The enrollee had a right sided ischemic stroke in 2011 with resultant left spastic hemiparesis. In this case, sufficient medical documentation indicating the need for the requested service has not been provided. The documentation provided indicates that a physical therapy and neurology referral would be made. The requested service is not medically necessary or reasonable based upon the provided documentation. The elements of the coverage rule are not satisfied. The requested service cannot be recommended. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a myoelectric prosthesis for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on October 22, 2020.

You asked the Plan to waive the coinsurance for an injection. You say that you have never paid this much for this injection before. The Plan denied your request. The Plan says the correct coinsurance has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs/network. 

You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $4,531.20. The total amount you are being asked to pay $906.24 ($4,531.20 x 20% = $906.24). An injection falls within the Medicare Part B prescription drugs/network benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on October 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says based on a review of the existing evidence, there are currently no clinical indications for
this technology.

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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the device is experimental. More research is needed to show safety and efficacy.

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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve enteral formula.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that items and 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is a diagnosis of protein-calorie malnutrition. In this case, the enrollee is using three cans per day. The documentation does not indicate the route of administration. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve enteral formula.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral periapical x-rays (D0220, D0230) and fluoride application (D1206) provided on November 10, 2020.
You asked the Plan to pay for the fluoride and x-rays. You say that these services should be covered because your dental provider says they are necessary. You believe intraoral periapical x-rays should be covered annually. The Plan denied your request. The Plan says that the fluoride application is not a service that is covered by Medicare or by the Plan's supplemental dental benefit. The Plan also says that intraoral x-rays are covered once per year, but they have already paid for this service this year. Therefore, your benefit for this service was already exhausted.
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 fluoride application is not among those covered under this benefit. Intraoral x-rays are a covered service; however, the Plan has provided documentation that they paid for this service when it was previously provided in October of 2020. The contract shows that intraoral x-rays are limited to one procedure per calendar year, which means you had already used up this benefit by the date of service in question. Therefore, we decided that the Plan does not have to pay for the intraoral periapical x-rays (D0220, D0230) and fluoride application (D1206) provided on November 10, 2020.
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 IRF care is medically necessary. The Plan denied your request. The Plan says rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 patient was admitted for myocardial infarction and congestive heart failure. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Finally, there is not a reasonable expectation that this patient 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found 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 was admitted for altered mental status, seizures, and respiratory failure. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses (L2397, L1833) provided October 3, 2020.
You asked the Plan to pay for the orthoses. You say that the braces were medically necessary. The Plan denied your request. The Plan says documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code L2397, & L1833 is not supported in the medical record. Specifically, the plan has no record of an in-person, telephonic, or video visit with the ordering physician. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for orthoses (L2397, L1833) provided October 3, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a replacement implantable loop recorder.
You asked the Plan to pre-approve a replacement implantable loop recorder. You say that the requested
replacement implantable loop recorder is medically necessary. The Plan denied your request. The Plan says that
the requested replacement implantable loop recorder is not medically necessary.
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 a replacement implantable loop
recorder. Our reviewer says that the requested replacement implantable loop recorder is medically necessary.
Our physician reviewer found the enrollee has had the implantable loop recorder (ILR) monitor implanted in
2017 because of infrequent palpitations. She last had documented (2) episodes of atrial fibrillation in 2018
according to the provider notes in the ILR log. She has had some asymptomatic bradycardia noted in the
middle of the night (presumably while sleeping) and several episodes of atrial tachycardia, the last in January
2021 for 6 mins duration, but was asymptomatic. As she does have poorly controlled hypertension and a
history of atrial arrhythmias, she remains at risk for recurrent atrial fibrillation. In addition, she has had recent
asymptomatic long episode atrial tachycardia which has been associated with atrial fibrillation especially in
patients with hypertension. Given the recent long AT noted considered a "long episode" at greater than 5 mins,
published data and expert opinion suggest an increased risk for recurrent atrial fibrillation and
thromboembolism which if found, would then make her a candidate for anticoagulation therapy based on her
current CHA2DS2VASc score. For this reason, given the high baseline risk of recurrent PAF, continued
monitoring with a replacement ILR would be considered medically reasonable and meets the CMS section
1862a general medical necessity criteria for medical reasonableness of the diagnostic procedure.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a replacement implantable loop recorder have been met. Therefore, we decided
that the Plan has to pre-approve a replacement implantable loop recorder.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ofev capsules.
You asked the Plan to pre-approve Ofev capsules. You say that you feel this drug would greatly benefit the enrollee. The Plan denied your request. The Plan says this medication does not fall under Part B coverage.
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 Ofev capsules.
Benefits for Ofev capsules 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 the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on November 24, 2020.
You asked the Plan to pay for the dental services. You say that you are very upset with your treatment and visits with your first choice of dentist. You say that you had no choice but to find another dentist. You say that this dentist was no help either. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 years. The Plan says that the frequency limit for this service has been exceeded. The Plan also says that complete series x-ray is not listed as a covered 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. Though the Plan offers a dental benefit in excess of Medicare coverage and comprehensive oral evaluation is listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on October 5, 2020. Additionally, the complete series x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on November 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthoses provided on September 16, 2020.
You asked the Plan to pay for knee orthoses. You say that you have no obligation to ensure that the physician has billed for their service prior to billing for these items. The Plan denied your request. The Plan says the denial of payment for these items is correct, because the ordering provider is not listed in the enrollee's history of claims and it appears these items were ordered by a prohibited telephonic solicitation.
The Plan must follow Medicare rules. Medicare rules say that a supplier of a covered DME item may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances. We looked at the file and Medicare rules. The Plan has attested that the enrollee was contacted by unsolicited phone call regarding provision of the billed items. As such, no payment can be made for the items. Based on this information, we decided that Medicare rules for coverage of knee orthoses have not been met. Therefore, we decided that the Plan does not have to pay for knee orthoses provided on September 16, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with congestive heart failure, recent gastrointestinal bleed, ischemic cardiomyopathy, rheumatoid arthritis and coronary artery disease. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She was treated for congestive heart failure. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at a supervision/stand by assist to contact guard/minimal assist level for functional mobility including gait to 100 feet with a rolling walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on May 7, 2020.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 psychotherapy services provided on May 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the cell enumeration using immunologic selection and identification in fluid specimen services coded 86153 provided on November 19, 2020.
You asked the Plan to pay for the cell enumeration using immunologic selection and identification in fluid specimen services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
Review of the file shows that the plan uses Local Coverage Articles A55598, A55593, A54292, and A55245 to support their denial. None of these Local Coverage Articles are valid for the provider's billing address state of Texas. Therefore, we are unable to use these Local Coverage Articles to substantiate our decision. We find that CPT code 86153 is not supported in the medical record. Specifically, this code needs to be billed with an appropriate DEX Z code identifier adjacent to the code. Based on this information, we decided that Medicare rules for coverage of the cell enumeration using immunologic selection and identification in fluid specimen services have not been met. Therefore, we decided that the Plan does not have to pay for the cell enumeration using immunologic selection and identification in fluid specimen services coded 86153 provided on November 19, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from August 10, 2020 to August 13, 2020.
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 procedure code G0299 is not supported.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. We looked at the file and Medicare rules. Billed procedure code G0299 (direct skilled nursing services in the home setting) has a status indicator of X and is excluded from payment. Therefore, we decided that the Plan does not have to pay for the home health services rendered from August 10, 2020 to August 13, 2020.