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

We decided that the Plan does not have to pay for physician's services you provided on August 29, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the services at 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 physician's services you provided on August 29, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the prophylaxis provided on November 20, 2019.
You asked the Plan to pay for the prophylaxis. You say that your understanding of your benefits is that you would have a $0 copay for the services you received from an out-of-network dentist. You also say that you confirmed with the Plan that you would have a $0 copay for services with your out-of-network dentist. The Plan denied your request. The Plan says that the Plan paid the allowed amount but since the provider is out-of-network, the provider can balance bill.
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 which must be presented clearly and accurately. The Plan covers the prophylaxis dental cleanings with a $0 copay when the services are provided both in-network and out-of-network. In this case, the Plan contract states that preventive services including dental exams, dental cleanings, and dental x-rays have a $0 copay when they are provided by an in-network or out-of-network provider. The Plan says that because the provider is out-of-network, the provider can balance bill. We find that there is no evidence saying that you would be responsible for the amount above the Plan's allowed fee, and you were not reasonably made aware that you would have to pay for the cleaning. Therefore, we decided that the Plan has to pay for the prophylaxis provided on November 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup (D2950).
You asked the Plan to pre-approve core buildup (D2950). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the 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 core buildup (D2950) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core buildup (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Onetouch Verio and test strips.
You asked the Plan to pre-approve Onetouch Verio and test strips. You say that the requested items 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. Medicare rules say that plans may specify brands and manufacturers as
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred
brands and manufacturers as long as the enrollee retains access to all medically necessary items (including nonpreferred
brands).
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of Onetouch Verio and test strips have not been met. Specifically, medical records were not provided.
Without this documentation, medical necessity for the specific brand requested is not able to be established.
Therefore, we decided that the Plan does not have to pre-approve Onetouch Verio and test strips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Lidocaine 5% patch for the enrollee.You asked the Plan to pre-approvethis drug. You say that the enrollee has low back and left leg pain.The Plan denied your request. The Plan says that this is not covered under the member's contract under any normal circumstances.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approvethe Lidocaine 5% patch for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appealrights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services for the enrollee.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says the enrollee does not need supervision by a rehab physician three times 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 physician reviewer found that the enrollee suffered post-stroke dysphagia and left hemiparesis. He has a PEG tube, but is eating pureed foods. 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 is at minimal assist for functional transfers and activities of daily living. The enrollee does not require treatment by multiple therapies, including physical or occupational therapy, and an intensive rehabilitation therapy 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 doesnot have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour Test Strips (A4253).
You asked the Plan to pre-approve Contour Test Strips. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is no medical reason documented that you are unable to use the Plan's preferred brand.
The Plan follows Medicare rules. The rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers. 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 Contour Test Strips. Our reviewer says that no medical records have been submitted for review. Our physician reviewer found there is no evidence that the non-preferred brand test strips is medically necessary to treat you.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Contour Test Strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Contour Test Strips (A4253).
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 a LTACH admission is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a
LTACH admission.
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 necessitating admission to a LTACH. The
enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute
care hospital (ACH). The review has determined that the enrollee does not require services at the LTACH that
are not available at the acute care hospital where he 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-approvea home blood pressure monitor (A4670) and blood pressure cuff (A4663).You asked the Plan to pre-approvea blood pressure monitor and cuff. You say that a home blood pressure monitor,and cuff are medically necessary for the enrollee.The Plan denied your request. The Plan says the enrollee has not been diagnosed with white coat hypertension; therefore,she does not meet criteria for coverage of a home blood pressure monitor and cuff under hercontractual policy.The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor and cuff arerequested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of these items in this situation.Therefore, we decided that the Plan does not have to pre-approvea home blood pressure monitor (A4670) and blood pressure cuff (A4663).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that an IRF admission is medically necessary for the enrollee.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.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. Our physician reviewer found that the enrollee's medical conditions appear stable. There are no current complex wound care needs and no unaddressed medical issues. He does not require medical oversight of his condition at an acute hospital level of care. The enrolleerequires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. There is no evidence that he requires an intensive therapy program. Additionally, the enrollee is limited by debility and the severity of his comorbid medical conditions as well as his obesity. He would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. An intensive rehabilitation therapy program would not significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. The enrollee's care can be appropriately provided at a skilled nursing facility level.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-approvean acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical injection at C1-C2
You asked the Plan to pre-approve the requested injections. The Plan denied your request. The Plan says injections are only covered between C2-3 and L5-S1.
The Plan follows Medicare rules. Medicare rules say that facet injections are only covered under certain medical 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 the requested injections. Our physician reviewer found that the enrollee has chronic neck pain, and acoustic neuroma status-post fractionated stereotactic radiosurgery. The enrollee noted 40% improvement following right suboccipital trigger point injections. The first three days after injections she felt 100% alleviation of pain, but it began to return. She continues to use Ibuprofen 400mg as needed. She uses Voltaren gel on her neck at night. The enrollee denies any neurological changes from the previous visit and denies bowel or bladder dysfunction. C1-C2 facet injections are considered experimental/investigational because there is not enough evidence of effectiveness in the literature. 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 requested injections have not been met. Therefore, we decided that the Plan does not have to pre-approve cervical injection at C1-C2
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from September 22,
2019 to October 11, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says by September
22, 2019 the enrollee's care could safely be provided by the extended care facility custodial level of care as it
had been prior to the SNF admission.
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 services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a 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 the skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from September 22, 2019 to October 11,
2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Prolia.
You asked the Plan to pre-approve Prolia. You say that the enrollee is in pain. The Plan denied your request. The Plan says the denial of authorization for Prolia is correct, because the Plan requires a trial of Zoledronic Acid or a history of osteoporotic fracture before it will approve Prolia.
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 Prolia. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Prolia. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drug of Zoledronic Acid. The documentation submitted does not indicate that Zoledronic Acid would likely be less effective and/or 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Prolia.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing services provided to the enrollee on September 7, 2019.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary and was not authorized.
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 the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found based on the results of a lung biopsy, the enrollee is noted to have melanoma with lung metastasis. The location of the primary melanoma (cutaneous, uveal) is not documented. Whether or not the enrollee had received, or was to receive treatment, is not documented. The documentation does not support that the provided genetic testing was medically necessary to diagnose or manage the enrollee's condition. 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 pay for genetic testing services provided to the enrollee on September 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvediabetic test strips.
You asked the Plan to pre-approve the requested test strips. The Plan denied your request. The Plan says this brand is not covered.
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers. We looked at the file and Medicare rules. The plan only covers certain brands of diabetic test strips. Freestyle Lite test strips are not covered under your plan. Based on this information, we decided that Medicare rules for coverage of the requested test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve diabetic test strips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not require transfer to the 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 the enrollee is currently undergoing treatment at an ACH for altered mental status. She has been treated for a UTI and worked up for seizure and stroke. The enrollee was intubated/ventilated upon arrival and subsequently received a tracheotomy. The enrollee has been weaned off the ventilator to a tracheotomy collar. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.