Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visitprovided on November 21, 2019.You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says the service is not a covered benefit.Medicare rules say that plans can require enrollees to get care from networkproviders. 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 servicesat 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 a domiciliary, rest home visit provided on November 21, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services with CPT code 99215 provided on August 27, 2020.You asked the Plan to pay forCPT code 99215. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered as billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We looked at the file and Medicare rules. CPT code 99215 has a status indicator of "B" and is not recognized by OPPS when submitted on an outpatient hospital Part B bill type 13X.Therefore, we decided that the Plan does not have to pay forthe physician services with CPT code 99215 provided on August 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that it is unclear if the member can benefit from and tolerate 3 hours of intensive therapy 5 days a week.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not require intensive physician or nursing supervision in an IRF. While the patient may benefit and participate in multiple therapies the patient's functional level does not appear to be able to tolerate or require therapy on an intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pulse oximeter (E0445, A4606).You asked the Plan to pre-approvethe pulse oximeter. You say that the pulse oximeter is medically necessary.The Plan denied your request. The Plan says this is not a covered item.The Plan must follow Medicare rules. Medicare rules say that Oximeters (E0445) and replacement probes (A4606) will be denied as non-covered.We looked at the file and Medicare rules. The requested item is non-covered. Based on this information, we decided that Medicare rules for coverage of the pulse oximeter have not beenmet.Therefore, we decided that the Plan does not have to pre-approvea pulse oximeter (E0445, A4606).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Swell Spot.
You asked the Plan to pre-approve the Swell Spot. You say that this item is medically necessary. The Plan
denied your request. The Plan says the requested item is not an item covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that Fabric Supports are not re-usable and do not
meet the Medicare definition of Durable Medical Equipment.
We looked at the file and Medicare rules. The requested item is non-covered. Based on this information, we
decided that Medicare rules for coverage of the Swell Spot have not been met. Therefore, we decided that the
Plan does not have to pre-approve a Swell Spot.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 19, 2020 by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were renderedby an out-of-network provider without 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 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 forthe medical services provided on October 19, 2020 by an out of network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says it is unlikely that you are able to tolerate three hours of therapy a day.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 physician reviewer found that you were admitted to the acute hospital for urinary tract infection and congestive heart failure. You were discharged home with home health care and have ongoing weakness. Your medical conditions are stable. There are no medical needs requiring inpatient admission. 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. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve biologic materials to aid in tissue regeneration with periradicular surgery (D3431) for teeth # 19 and 30.
You asked the Plan to pre-approve the dental services. You say that the root canals for teeth # 19 and 30 were approved but the biologic materials to aid in tissue regeneration with periradicular surgery for teeth # 19 and 30 were not. The Plan denied your request. The Plan says biologic materials to aid in tissue regeneration with periradicular surgery 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, 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 biologic materials to aid in tissue regeneration with periradicular surgery (D3431) for teeth # 19 and 30.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea sacral lateral nerve branch block for the enrollee.You asked the Planto pre-approvethe block. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is considered experimental and investigational.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 block. Our reviewer says that the requested block is not considered medically reasonable and necessary in this case. Our physician reviewer found sacroiliac (SI) joint ablation is experimental.  More research is needed to show safety and efficacy. The use of radiofrequency ablation for pain management related to sacroiliitis has not been shown to provide clear long-term benefit than standard treatment for chronic sacroiliac joint pain. Based upon the review of the medical literature, radiofrequency ablation used for sacroiliac joint pain is considered experimental and not medically necessary -whether using traditional, cooled, or pulsed radiofrequency.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 block have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea sacral lateral nerve branch block for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity.
You asked the Plan to pre-approve Evenity. You say that Evenity will reduce the enrollee's risk of further fractures. The Plan denied your request. The Plan says the enrollee has not tried Forteo or Tymlos.
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 Evenity. Our physician reviewer found that the enrollee has postmenopausal osteoporosis. The enrollee has failed treatment with Fosamax and Prolia. The Plan requires a trial of Forteo or Tymlos before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective, 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 Evenity have not been met. Therefore, we decided that the Plan does not have to pre-approve Evenity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair repair.
You asked the Plan to pre-approve the repair. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria was not 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. 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 repair. Our reviewer says that the requested repair is not medically reasonable or necessary. Our physician reviewer found the documentation does not reveal that you are unable to perform MRADLs in the home with the current wheelchair. The documentation does indicate why you would be unable to use a manual wheelchair. The documentation does not indicate that you could safely maneuver the requested wheelchair in your home. There is no evidence that your current wheelchair needs repairs. 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 repair have not been met. Therefore, we decided that the Plan does not have to pre-approve power wheelchair repair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea tub stool/bench.You asked the Planto pre-approvethe item. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not primarily medical in nature.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plandoes not haveto pre-approvea tub stool/bench
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean occlusal guard (D9944).You asked the Plan to pre-approvethe occlusal guard. You say that your previous mouth guard was 20 years old and recently broke. You also say that this guard is medically necessary.The Plan denied your request. The Plan says this service is not covered under your plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. Forthat 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-approvean occlusal guard (D9944).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran office visit with an ophthalmologist (92004) provided on October 5, 2020.You asked the Plan to waive the copayment foran office visit with an ophthalmologist. You say that you didn't have to pay for this service in the past.The Plan denied your request. The Plan says this processed 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 $40 copayment for each specialist office visit. You have been asked to pay a $40 copayment for an office visit with an ophthalmologist, which is considered a specialist. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is acontractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran office visit with an ophthalmologist (92004) provided on October 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea total electric hospital bed.You asked the Plan to pre-approvea total electric hospital bed. You saythat because of medical conditions you want to sleep sitting up.The Plan denied your request. The Plan says total electric hospital beds are not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approvea total electric hospital bed
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveenteral formula (Glucerna).You asked the Plan to pre-approveenteral formula. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested items are not medically necessary.The Plan follows Medicare rules. Medicare rules say that enteral formula is only covered for certain indications.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 enteral formula. Our reviewer says that the documentation does not support that the requested items are medically reasonable or necessary. Our physician reviewer found the enrollee has abnormal weight loss. 
The documentation does not support that the enrollee in this case has pathology to, or non-function of, the structures that normally permit food to reach the digestive tract, and cannot maintain weight and strength commensurate with the enrollee's general condition. While some enrollees require supplementation of their daily protein and caloric intake. Nutritional supplements are often given as a medicine between meals to boost protein-caloric intake or the mainstay of a daily nutritional plan. Nutritional supplementation is not covered under Medicare Part B. Therefore, the enrollee does not meet criteria for the requested items.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of enteral formula have not been met.Therefore, we decided that the Plan does not have to pre-approveenteral formula (Glucerna).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea tier exception for Perforomist20mcg/2ml solution.You asked the Plan to pre-approvea tier exception for Perforomist. You say that the tier exception for Perforomist is necessary.The Plan denied your request. The Plan says this drug is not eligible for a tier exception.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for a tier exception have not been met. Specifically, the requested drug is a Medicare Part B Prescription Drug. Part B Drugs are not eligible for a tier exception.Therefore, we decided that the Plan does not have to pre-approvea tier exception for Perforomist 20mcg/2ml solution.
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. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean implantable loop recorder (33285).You asked the Plan to pre-approvethe implantable loop recorder. You say that the implantable recorder is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that implantable loop recorders are covered when 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 implantable loop recorder. Our reviewer says that the implantable loop recorder is not medically necessary. Our physician reviewer found the enrolleehas no history of syncope or cryptogenic stroke and had a history of sporadic palpitations only.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 implantableloop recorder have not been met.Therefore, we decided that the Plan does not have to pre-approvean implantable loop recorder (33285).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea group 2 standard power wheelchair.You asked the Planto pre-approvethe wheelchair. You say that this is medically necessary.The Plandenied your request. The Plansaysthe medical notes sent in are conflicting.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. 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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the documentation is conflicting in whether or not you have a personal mobility deficit. It is not clear that this deficit impairs participation in MRADLs, or why your mobility deficit cannot be helped by the use of a cane, walker, or manual wheelchair. The physician progress notes indicate normal neuromuscular exam and strength and well as painless full range of motion. This is in contrast to the therapist note indicating weakness. The documentation does not indicate that you safely operate the power wheelchair.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicarerules for coverage of the wheelchair have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea group 2 standard power wheelchair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission and services.You asked the Plan to pre-approveSNF services. You say that if the enrollee gets fluid in his lungs, there will be a problem.The Plan denied your request. The Plan says the enrollee has no skilled nursing or therapy service needs.The Plan must follow Medicare rules. The rules saythat 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 physician reviewer found that the enrollee is able to ambulate up to 300 feet independently,and is independent with transfers and modified independent with toileting. Heis also tolerating an oral diet.He does not have any complex daily wound care, parental medications or required care for a feeding tube. There has not been a significant decline in function due to the acute illness. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis.Therefore, admission to a SNF is 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission and services