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

We decided that the Plan does not have to pay for an LSO (L0650) provided on September 5, 2020.
You asked the Plan to pay for an LSO. You say that the enrollee is using this medically necessary item with benefit. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for an LSO. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was back pain. The available documentation in the case file does not support that the requested LSO was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the LSO was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the back. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an LSO have not been met. Therefore, we decided that the Plan does not have to pay for an LSO (L0650) provided on September 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a right knee orthosis (L1833) and a suspension sleeve (L2397).

You asked the Plan to pay for a knee orthosis and a suspension sleeve. You say that the enrollee is using these medically necessary items with benefit. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for a knee orthosis and a suspension sleeve. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was chronic pain located in the bilateral knees. The documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. There is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.

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 knee orthosis have not been met. Furthermore, a suspension sleeve is not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pay for a right knee orthosis (L1833) and a suspension sleeve (L2397).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D9610).
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.
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 dental services (D9610).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional wheelchair accessories (E2211, K0043).
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says these items are not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The items 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 additional wheelchair accessories (E2211, K0043).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the Plan requires the enrollee to receive care from providers who are part of the enrollee's primary care physician's specialty network. The provider you requested is not part of your primary care physician's network
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bi-level positive airway pressure (BiPAP) machine and supplies (E0470) for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the information provided with the request did not include a full evaluation with settings.
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 the enrollee has severe obstructive sleep apnea (OSA), and has been on continuous positive airway pressure (CPAP). At the visit on 12/8/20, the enrollee complained that the pressure was too high. BiPAP has been requested for the enrollee, but there is no order that provides the BiPAP settings. There is no documentation that CPAP is inadequate for treatment of the enrollee's OSA. For example there is no information from a download to assess the residual AHI and compliance with use. BiPAP is therefore 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a bi-level positive airway pressure (BiPAP) machine and supplies (E0470) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewings (D0274), and prophylaxis (D1110) provided on September 25, 2020.
You asked the Plan to pay for the periodic oral evaluation, bitewings, and prophylaxis. You say that you thought that the dental rider had covered the crown you received earlier in the year. You also say that you thought the cleaning would be covered under the routine dental coverage. The Plan denied your request. The Plan says you have exceeded the limits set in the subscriber agreement.
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 Plan offers a $500 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on July 13, 2020 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewings (D0274), and prophylaxis (D1110) provided on September 25, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from February 1, 2020 to March 11, 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 the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed with the appropriate TOB and required RAP claim. We looked at the file and Medicare rules. The file shows that the claims were not billed with the correct TOB code and required RAP claim. 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 home health services rendered from February 1, 2020 to March 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air ambulance services (A0431, A0436).

You asked the Plan to pay for air ambulance services. You say that this was medically necessary. The Plan denied your request. The Plan says the enrollee could have been transported by ground ambulance.

The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate.

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 air ambulance services. Our reviewer says that the criteria for coverage of air ambulance services were not met. Our physician reviewer found the documentation does not support that the patient suffered from an illness or injury that contraindicated transportation by any means other than ambulance. The documentation did not support that the patient's condition was such that the time needed to transport a patient by ground, or the instability of transportation by ground, posed a threat to the patient's survival or seriously endangered the patient's health. The documentation did support that the transferring hospital did not have adequate facilities to provide the medical services needed by the patient.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of air ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for air ambulance services (A0431, A0436).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the patient assisted living visit (99335) provided on July 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the patient visit. You say that you are contracted with the assisted living facility and may be called at any time to evaluate a patient. You say that you are covered under the facility referral as a primary care physician. The Plan denied your request. The Plan says that no referral provided by a contracted provider was submitted for review. The services were not urgent or pre-approved. The Plan only covers out of network services in limited circumstances.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the patient assisted living visit (99335) provided on July 15, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio (J3380).
You asked the Plan to pre-approve Entyvio. You say that Entyvio would be highly beneficial for the enrollee's
treatment. The Plan denied your request. The Plan says the information submitted does not meet the Plan's
medical necessity guidelines for coverage.
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 Entyvio. Our reviewer says that
Entyvio (J3380) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the
Plan requires a trial of drug Stelara before they will approve the requested drug. Our reviewer found that the
enrollee has not tried and failed the required drug(s). Our physician reviewer also found that there is no
documentation provided indicating that the Plan's required drug(s) 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 Entyvio have not been met. Therefore, we decided that the Plan does not have
to pre-approve Entyvio (J3380)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of March 1, 2021.
You asked the Plan to pre-approve inpatient psychiatric care. You say that you are not mentally stable to take care of yourself and are not safe to discharge. The Plan denied your request. The Plan says the denial of authorization for continued inpatient psychiatric care is correct, because you can be treated in a lower level of care such as intensive outpatient treatment.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric care. Our reviewer says that you do not meet the Medicare criteria for continued inpatient psychiatric care as of March 1, 2021. Our physician reviewer found it is not expected that you would improve in a reasonable period of time beyond the date in question as you do not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. You were compliant with treatment while not showing any acute threats to safety, socializing with peers, and attending and participating in groups. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of March 1, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (EGD) provided on September 25, 2020.
You asked the Plan to waive the copayment for EGD. You say that you were not informed of a copayment prior to the procedure, and this charge creates a financial hardship for you. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $250 copayment for EGD at an outpatient hospital facility. You have been asked to pay $250 copayment for EGD. EGD falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 copayment for an esophagogastroduodenoscopy (EGD) provided on September 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Opdivo.
You asked the Plan to pre-approve Opdivo. You say that the enrollee has stage 4 colon cancer and is progressing with treatment. The Plan denied your request. The Plan says the denial of authorization for Opdivo is correct, because no compendia or other phase 2 or greater study support was found for this requested drug regimen.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Opdivo. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of Opdivo. Our physician reviewer found the requested use of Opdivo is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. The requested use is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Opdivo.
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 treatment is important for member's recovery.
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 complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, you do 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 you 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 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 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. There is not a reasonable expectation that this enrollee 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.