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

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. The Plan denied your request. The Plan says that there was no evidence of the need for skilled nursing.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forShoulder elbow wrist hand orthosis (SEWHO) (L3960).You asked the Plan to pay forthe orthosis. You say that the provided records should support the necessity of the service in dispute.The Plan denied your request. The Plan says there is insufficient documentation to corroborate the service so that the Medicare coverage criteria has been met. The plan says that this item was previously provided by another provider on 8/20/2018.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery or a delivery ticket for the supplies provided in this case.Therefore, we decided that the Plan does not have to pay forShoulder elbow wrist hand orthosis (SEWHO) (L3960)
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz for enrollee.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the step therapy requirement is not met.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has pain in the right knee and has not triedand failed the plan's required drugs of gluticosteroid injection, Synvisc One, and Euflexxa. The records do not show that the required drugs would be less effective or contraindicated; therefore, Supartz is not reasonable or medically necessary at this time.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-approveSupartz for enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. The Plan denied your request. The Plan says LTACH admission is not medically necessary.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 is currently undergoing treatment at an acute care hospital (ACH) for multifactorial shortness of breath. The enrollee has received antibiotics, diuretics, steroids and supplemental oxygen. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHsare licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs.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, wedecided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services (96375, 96376, 99291 and 92950) provided on February 10, 2018.
You asked the Plan to pay for the hospital services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim was received past the allowed 12-month time frame.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the hospital services was not filed until August 6, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for hospital services (96375, 96376, 99291 and 92950) provided on February 10, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from September 6, 2019.You asked the Plan to pay for the home health services. You say that the member revoked hospice services on September 4, 2019 and the admission date for services was September 6, 2019. The Plan denied your request. The Plan says the Medicare hospice benefits covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. The record shows the patient was enrolled in hospice from July 11, 2019 to September 4, 2019. However, Medicare is still responsible for payment until the start of the next month after revocation.Therefore, we decided that the Plan does not have to pay forthe home health services provided from September 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on June 12, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the records did not included a lab order.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on June 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat.
You asked the Plan to pre-approve a raised toilet seat. The Plan denied your request. The Plan says the item is not a covered benefit within the enrollee's plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal 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. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ranolazinetab 1000mg 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 the drug in question is not covered under the enrollee's contract under any normal circumstancesThe 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 Ranolazine tab 1000mg for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ofev for the enrollee.
You asked the Plan to pre-approve Ofev. You say that the medication is medically necessary for treatment of the enrollee's condition. The Plan denied your request. The Plan says Ofev to be taken at home is not covered under the Part B benefit.
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 for the enrollee.
Benefits for Ofev 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for enrollee.You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires vent weaning, close monitoring, speech therapy, and aggressive physical and occupational therapy.The Plan denied your request. The Plan says the enrollee has not completed the full course in the hospital.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 is currently undergoing treatment at an acute care hospital (ACH). Initially treated for pneumonia and sepsis, the enrollee was subsequently evaluated for toxic epidermal necrolysis. The enrollee was intubated/ventilated and only recently received a tracheotomy, after which she was to start extended ventilatorweaning trials. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.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-approvelong term acute care hospital (LTACH) services for enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tertiary-level referral to an OON provider for an MRI.
You asked the Plan to pre-approve the tertiary referral. You say that this is medically necessary. The Plan denied your request. The Plan says a tertiary level of care is not needed.
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 tertiary referral. Our reviewer says that the requested referral is not considered medically reasonable and necessary in this case. Our physician reviewer found according to the provided records, a request was made for MRI right knee to be performed at the OON provider, whereas the Plan preferred they have the MRI at the contracted an in-network provider where they also provide MRI services for those with pacemakers, such as is the case with this enrollee. Appropriate, accurate, and safe MRI services are available at the preferred location. There was no indication or explanation for not having the MRI at the network provider to justify this request. Therefore, this request for MRI right knee at the OON provider will be considered 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 tertiary referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a tertiary-level referral to the OON provider for an MRI.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan provided on September 9, 2019.
You asked the Plan to waive the copayment for the duplex scan. You say that it is unfair that you have to pay more than insurance has to pay. You say that the copayment is not correct. The Plan denied your request. The Plan says the copayment applied correctly.
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 $100 copayment for each Medicare-covered radiological diagnostic service. Covered services include specialized scans, CT, SPECT, PET, MRI, MRA, nuclear studies, ultrasounds, diagnostic mammograms and interventional radiological procedures (myelogram, cystogram, angiogram, and barium studies). You have been asked to pay a $100 copayment for the duplex scan. The duplex scan falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The duplex scan is considered an ultrasound. 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 copayment for the duplex scan provided on September 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDiclofenac Sodium gel.You asked the Plan to pre-approveself-administered drugs. You say that this is medically necessary for the enrollee's condition.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.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-approveDiclofenac Sodium gel.Benefits for self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forhyperbaric oxygen (HBO) therapyYou asked the Plan to pay forHBO therapy. You say that this was medically necessary.The Plan denied your request. The Plan says the enrollee has skin ulcers.The Plan follows Medicare rules. Medicare rules say that HBO therapy is not covered for the treatment of cutaneous, decubitus, and stasis ulcers or chronic peripheral vascular insufficiency.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 HBO therapy. Our reviewer says that the criteria for coverage of HBO therapy have not been met. Our physician reviewer found the records show that the enrollee has painful skin ulcers of the extremities, torso, pannus, and penis and calciphylaxis. This description best is described by the non-covered "cutaneous, decubitus, and stasis ulcers" condition category as well as the non-covered "chronic peripheral arterial insufficiency" category.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of HBO therapy have not been met.Therefore, we decided that the Plan does not have to pay forhyperbaric oxygen (HBO) therapy
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 genetic testing provided on October 29, 2019.
You asked the Plan to pay for Guardant360. You say that this testing was deemed medically necessary, and the enrollee did not have an in-network provider option. The Plan denied your request. The Plan says the denial of payment for this service is correct, because Guardant360 is not covered by Medicare under these conditions.
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing is only covered for enrollees who have been diagnosed with advanced non-small cell lung cancer and who meet certain criteria. We looked at the file and Medicare rules. The documentation submitted does not show that the enrollee had been diagnosed with advanced non-small cell lung cancer at the time this testing was performed. Based on this information, we decided that Medicare rules for coverage of Guardant360 have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 genetic testing provided on October 29, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approvediagnostic medial branch block (MBB) injections.You asked the Plan to pre-approvediagnostic medial branch blocks. You say that you are appealing with medical records.The Plan denied your request. The Plan says that the denial of authorization for these services is correct, because there is no clinical documentation to show that the enrollee has tried all alternative conservative treatments.The Plan must follow Medicare rules. Medicare rules say that diagnostic medial branch blocks are covered when the enrollee meets certain criteria for medical necessity.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 diagnostic medial branch blocks. Our reviewer says that the enrollee meets the Medicare criteria for the requested diagnostic medial branch blocks. Our physician reviewer found the enrollee has documented facet joint arthropathy and has failed conservative therapy. The requested procedure is therefore medically reasonable and 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 diagnostic medial branch blocks have been met.Therefore, we decided that the Plan has to pre-approvediagnostic medialbranch block (MBB) injections. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel Sureclick Injectors.
You asked the Plan to pre-approve Enbrel. The Plan denied your request. The Plan says this drug 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 Enbrel Sureclick Injectors.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) and a wrist-hand orthosis (L3916) provided to the enrollee on October 21, 2019.You asked the Plan to pay forthe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) and a wrist-hand orthosis (L3916) provided to the enrollee on October 21, 2019.