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

We decided that the Plan does not have to pay for the pneumatic compression device and appliances provided on August 21, 2020.

You asked the Plan to pay for the pneumatic compression device (E0675) and appliances (E0673). You say that the place of service code is correct. The Plan denied your request. The Plan says the device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery and payment for this device would have been included in the facility payment.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0675) is a preventive service. 

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, this item is not a covered benefit of Medicare or the Plan.

This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and appliances provided on August 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the heel wedge provided on March 10, 2021.
You asked the Plan to pay for the heel wedge. You say that correct treatment was given. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although the provided item may be appropriate for you, neither Medicare nor the Plan provides coverage for your condition. Therefore, we decided that the Plan does not have to pay for the heel wedge provided on March 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nucala.

You asked the Plan to pre-approve Nucala. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Nucala. Our reviewer says that the requested drug is not medically necessary and reasonable. Our physician reviewer found Nucala is a treatment for severe persistent asthma of eosinophilic phenotype that is not adequately controlled on maximum medical therapy. This patient has asthma-chronic obstructive pulmonary disease overlap and bronchiectasis; Nucala has not been shown to be effective for either of these diagnoses. The diagnosis of asthma is not supported in the record by pulmonary function testing results. The patient does not have eosinophilia. There is no clearly documented benefit from Nucala; the patient has been on it since December 2020. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Nucala have not been met. Therefore, we decided that the Plan does not have to pre-approve Nucala.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The
Plan denied your request. The Plan says the enrollee is receiving medically necessary acute and/or critical care
and does not require transfer to a LTACH.
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 there is no documentation provided indicating medical necessity for admission to
a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not
require services at the LTACH that are not available at the acute care hospital where he/she is currently
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at
the health care setting being offered by the health plan. The requested LTACH services are not medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished
safely and effectively only on an inpatient basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the thoracic lumbar sacral orthosis provided to the enrollee
on April 21, 2021.
You asked the Plan to pay for the orthosis. You say that this was medically necessary for the enrollee. The Plan
denied your request. The Plan says that they were unable to discover any evidence of an established
relationship between the member and the ordering physician.
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 does not contain relevant medical records which support medical necessity for the supplies provided
in this case. The record shows that the Plan made several attempts to obtain the necessary documentation
without success. Therefore, we decided that the Plan does not have to pay for the thoracic lumbar sacral
orthosis provided to the enrollee on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on May 11, 2021 by an out-ofnetwork
(OON) provider.
You asked the Plan to pay for office visit. You say that the enrollee was seen to discuss his conditions. The
Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider
is out-of-network with the Plan and authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 an office visit provided on May 11, 2021 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 inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for the enrollee's condition. 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 that the patient was admitted for lumbar laminectomy and fusion. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation
therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. In conclusion, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services provided on January 14, 2021.

You asked the Plan to pay for the services provided. You say that the services were justified. The Plan denied your request. The Plan says the service is included in the global surgery package.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.

We looked at the file and the rules. The service at issue is not eligible for separate reimbursement without an appropriate modifier. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the surgery services provided on January 14, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyaluronan or derivative, gel-one injection (CPT code J7326), for the enrollee.
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says there is a history of adverse side effects or intolerance to the formulary alternative, Synvisc, but not to Durolane, and Gelsyn-3 and this is not a continuation of therapy in the past 365 days based on the available information. The Plan states the Part B step therapy denial for Gel-One is therefore upheld.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer found the documentation does not support that Durolane, Gelsyn-3, and Synvisc/Synvisc-One have been tried and failed. The documentation does not support that Durolane, Gelsyn-3, and Synvisc/Synvisc-One would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 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 medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyaluronan or derivative, gel-one injection (CPT code J7326), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0150), the complete series x-ray (D0210), core build up (D2950), crown (D2740), periodontal maintenance (D4910), and fluoride application (D1208) provided from January 2, 2021, to April 21, 2021.
You asked the Plan to pay for the dental services. You say that you needed this work done while you were in another state for the winter. You say that the dentist advised they accept your insurance. You also say that you were not aware that you needed prior approval for the dental work that you needed to get done while you were out of state. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services performed out of network are not covered.
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, dental services performed out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral exam (D0150), the complete series x-ray (D0210), core build up (D2950), crown (D2740), periodontal maintenance (D4910), and fluoride application (D1208) provided from January 2, 2021, to April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid;
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (CPT code
64483) and injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance
(fluoroscopy or CT), lumbar or sacral, each additional level (CPT code 64484), for the enrollee.
You asked the Plan to pre-approve the injections. You say that the services are necessary. The Plan denied your
request. The Plan says they do not see the enrollee's previous injections provided relief of at least six (6) weeks.
The Plan states they do not see that it has been at least six (6) months since previous injection.
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 injections. Our physician reviewer
found the enrollee did not achieve sustained relief from the right sided injection and does not meet the criteria
of the LCD. Therefore, the request is considered not medically reasonable or 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve
injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or
CT), lumbar or sacral, single level (CPT code 64483) and injection(s), anesthetic agent(s) and/or steroid;
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level
(CPT code 64484), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on April 23, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring provider is also out-of-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 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 lab work provided on April 23, 2021 by an out-of-network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new pair of eyeglasses (V2783, V2020, V2200).
You asked the Plan to pre-approve eyeglasses. You say that you broke your last pair of glasses and need new ones. The Plan denied your request. The Plan says you have already used $258.96 of your $275 benefit allowance for the next two years. You still have $16.04 left in your benefit, but the Plan cannot cover new glasses for any amount greater than what you have left in your benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $275 for eye wear (contact lenses or eyeglasses (lenses and frames)) every two years. We looked at the file and the Plan's rules. Documentation shows that you used $258.96 of your benefit allowance on March 30, 2021, and have $16.04 remaining. You may use this toward a new pair of glasses; however, the cost of a new pair of glasses will exceed the amount you have remaining and you will be responsible for the remainder of the cost above the Plan's benefit limit. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pre-approve the full cost of a new pair of eyeglasses (V2783, V2020, V2200).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you still need physical and occupational therapy to get better. The Plan denied your request. The Plan says that your current care needs are mostly custodial.
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 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-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on March 22, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for lab test. You say that this testing was medically necessary. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan 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 laboratory testing provided on March 22, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive dental procedure provided on
April 15, 2021.
You asked the Plan to pay for the dental service. You say that you were told the copay would be canceled. The
Plan denied your request. The Plan says the claim processed correctly.
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.
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified
preventive dental procedure provided on April 15, 2021.
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 requested admission to an IRF is not medically necessary.
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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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