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

We decided that the Plan does not have to pay for the medical services provided on September 24, 2020 by an out of network (OON) provider.

You asked the Plan to pay for office visit. You say that there were no in-network providers within a 50 mile radius and you could not wait for treatment. 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 you could have been treated by an in-network specialist.

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 medical services provided on September 24, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the first 15 minutes of deep sedation/general anesthesia (D9222) and each subsequent 15 minute increment of deep sedation/general anesthesia (D9223).

You asked the Plan to pre-approve the deep sedation/general anesthesia services. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services 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, 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 the first 15 minutes of deep sedation/general anesthesia (D9222) and each subsequent 15 minute increment of deep sedation/general anesthesia (D9223).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility services from June 1, 2019, to April 30, 2020.

You asked the Plan to pay for the skilled nursing facility services. You say that the enrollee was entitled to up to 100 days of SNF benefits on a yearly basis. The Plan denied your request. The Plan says the records do not demonstrate any skilled nursing or skilled therapy needs.

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 pay for the skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found regarding rehabilitation services, there are no records to indicate that the beneficiary received or required skilled therapy. There are no identifiable skilled therapy service needs. The enrollee did not require skilled nursing or therapy services on a daily basis. This enrollee did not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility services from June 1, 2019, to April 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tertiary-level referral to a gastroenterologist for the enrollee.

You asked the Plan to pre-approve the referral. You say that this can be done at the community level. The Plan denied your request. The Plan says this can be done at the community level.

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 referral. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found esophageal manometry and 24-hour pH testing are widely available gastroenterology tests performed in most GI specialty practices. In general, CPT services 99205, 91010, 91034, and 91038 do not require performance at a tertiary care center in evaluation of gastroesophageal reflux. The enrollee's clinical circumstances do not warrant a tertiary level of care. Local expertise for these studies is available. 

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 referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a tertiary-level referral to a gastroenterologist for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry with electrocardiographic recording.

You asked the Plan to pre-approve external mobile cardiovascular telemetry with electrocardiographic recording (93228, 93229). You say that the enrollee needs external mobile cardiovascular telemetry. The Plan denied your request. The Plan says medical records show the member is not having palpitations, dizziness, presyncope or syncope.

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 external mobile cardiovascular telemetry with electrocardiographic recording (93228, 93229). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient has no symptoms of palpitations, syncope or dizziness. Based on both the CMS LCD criteria and appropriate medically necessity, mobile cardiac telemetry as an initial diagnostic procedure, in the absence of evidence of arrhythmia or symptoms of syncope or severe palpitations, is not medically necessary. Mobile cardiac telemetry would be reserved for severe, life threatening symptoms of syncope or possible rhythm disturbances where immediate recognition and action may be required, which is not the case in this clinical situation. It does not fit the CMS LCD coverage rules and is also not 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 external mobile cardiovascular telemetry with electrocardiographic recording (93228, 93229) have not been met. Therefore, we decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry with electrocardiographic recording.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 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 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 documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires at least 3 hours a day for 5 days a week, or 15 hours over 7 consecutive days, of therapy services. It is unclear that the 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 for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on July 24, 2020.

You asked the Plan to pay for the ambulance services. You say that you had fallen, and the medics assisted you back up. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on July 24, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on July 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue regeneration (D4265 x2), guided tissue regeneration (D4266), and bone replacement graft for ridge preservation (D7953).

You asked the Plan to pre-approve the biologic materials, guided tissue regeneration, and bone replacement graft. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered under your benefit plan.

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 soft and osseous tissue regeneration (D4265 x2), guided tissue regeneration (D4266), and bone replacement graft for ridge preservation (D7953).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FlowerAmnioFlo (Q4177).

You asked the Plan to pre-approve FlowerAmnioFlo. You say that you would like this drug to be approved because it is less invasive, and your pain is getting worse. The Plan denied your request. The Plan says amniotic fluid products are considered experimental and investigational in treatment. The Plan also says that without more quality evidence of efficacy in the medical literature, it is not considered medically reasonable and necessary per Medicare criteria.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 FlowerAmnioFlo. Our reviewer says that FlowerAmnioFlo is not medically reasonable and necessary for the enrollee. Our physician reviewer found based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that FlowerAmnioFlo (Q4177) is Food and Drug Administration (FDA)-approved for your diagnosis. Our reviewer found that there is no documentation that supports the use of FlowerAmnioFlo for you. Based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that FlowerAmnioFlo is indicated, supported or recommended in any of the compendia for your diagnosis. Our physician reviewer also found that there is no documentation that FlowerAmnioFlo is safe and effective and otherwise reasonable and necessary for this 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 FlowerAmnioFlo have not been met. Therefore, we decided that the Plan does not have to pre-approve FlowerAmnioFlo (Q4177).
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 for the enrollee. The Plan denied your request. The Plan says LTACH care 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 there is no documentation provided necessitating admission to an 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 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 pre-approve a protective outer surface covering system (L5962).

You asked the Plan to pre-approve this item. You say that this item is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of a protective outer surface covering system as the documentation provided does not indicate that you have special needs for protection against unusually harsh environmental situations.

The Plan follows Medicare rules. Medicare rules say that protective outer surface covering systems (L5962, L5964, and L5966) are specialized covers intended to be worn over an existing prosthesis. They are used by a beneficiary who has special needs for protection against unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of protection that is afforded by L5704, L5705, L5706, and L5707.

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 this item. Our reviewer says that this item is not medically necessary. Our physician reviewer found that the documentation provided does not indicate that you are exposed to unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of protection that is afforded by a lower limb prosthetic cover coded as L5704, L5705, L5706, and L5707.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have not been met. Therefore, we decided that the Plan does not have to pre-approve a protective outer surface covering system (L5962).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epoetin Alfa (Procrit).

You asked the Plan to pre-approve Procrit. 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 Procrit. Our reviewer says that Procrit is not shown to be currently medically necessary and reasonable for the enrollee. Our physician reviewer found the enrollee is noted to have anemia and chronic kidney disease. The Plan requires that other forms of anemia medications be used. Our reviewer found that there is no evidence that the enrollee is allergic to or intolerant of these other forms of medication. There is no evidence that the enrollee has tried and not responded to these other forms of medication. Our physician reviewer also found that there is no documentation as to why these other forms of medication would not be expected to be safe and effective 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 Procrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Epoetin Alfa (Procrit).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the first 15 minutes of deep sedation/general anesthesia (D9222), each additional 15 minute increment of deep sedation/general anesthesia (D9223), and therapeutic parenteral drugs (D9612).

You asked the Plan to pre-approve the deep sedation/general anesthesia services and therapeutic parenteral drugs. You say that you need these services. The Plan denied your request. The Plan says these services are not covered under your plan.

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.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the enrollee needs therapy so that she can get stronger but has missed it due to COVID and surgery. The Plan denied your request. The Plan says the denial of authorization for continued SNF care.

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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio 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 records do not indicate that step therapy has been followed.

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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the office visit note does not document any other treatment with immunomodulator therapy, such as azathioprine, methotrexate, 6 mercaptopurine or corticosteroids. In addition, Inflectra has no age limitations as the reason for not trying this medication. The review has determined that the plan requires a trial of Inflectra or similar before they will approve the requested drug. In this case, the patient has not tried and failed the required drug. There is no documentation provided indicating that the plan's required drugs 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stem cell injections for osteoarthritis for the enrollee.

You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is experimental and investigational in the setting of osteoarthritis.

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 injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found stem cell injections remain experimental for the treatment of osteoarthritis. More research is needed to show safety and efficacy of stem cell injections.

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 stem cell injections for osteoarthritis for the enrollee.