Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from January 14, 2021, to January 27, 2021.
You asked the Plan to pay for the SNF services provided from January 14, 2021, to January 27, 2021. You say that the services are coverable by the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require skilled services from January 14, 2021, to January 27, 2021.
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 pay for the SNF services provided from January 14, 2021, to January 27, 2021. 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 SNF services provided from January 14, 2021, to January 27, 2021 have not been met. Specifically, the enrollee did not require daily skilled services on the dates of service in this case. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from January 14, 2021, to January 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas Treatment combined with subcutaneous Nutri-Pharmaceutical injections billed with CPT codes J3490, J3411, J3415, J3420, J1955, 99072 and 99211 on January 27, 2021. You asked the Plan to pay for the Sanexas Treatment and Nutri-Pharmaceutical injections. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says the documentation submitted does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The HCPCS/CPT Code Manual definition of code 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease. Payment for CPT code 99072 is not supported. Specifically, CPT code 99072 has a status indicator of B and is not recognized as a separately payable procedure. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J1955 is injection, levocarnitine, per 1 gm. The HCPCS/CPT Code Manual definition of code J3420 is injection, vitamin b-12 cyanocobalamin, up to 1000 mcg. Payment for CPT codes J3490, J3411, J3415, J3420 and J1955 is not supported. Specifically, claims for compounded drugs shall be submitted using a compounded drug code. The HCPCS/CPT Code Manual definition of code 99211 is office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. The record does not support that a separate and distinct evaluation and management service was provided as all services were related to the treatment provided. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Sanexas Treatment and Nutri-Pharmaceutical injections have not been met. Therefore, we decided that the Plan does not have to pay for the Sanexas Treatment combined with subcutaneous Nutri-Pharmaceutical injections billed with CPT codes J3490, J3411, J3415, J3420, J1955, 99072 and 99211 on January 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synergy wheels, a match frame caster rim, and sidebands for a manual wheelchair.

You asked the Plan to pre-approve wheelchair accessories. You say that you need this to drive by yourself so you can put your wheelchair in an out of your car. The Plan denied your request. The Plan says the denial of authorization for these items is correct, because you do not meet the criteria.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve Synergy wheels, a match frame caster rim, and sidebands for a manual wheelchair.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 9, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all
hospice care from the effective date of election to the date of discharge or revocation. During the election, feefor-
service Medicare also covers attending physician services and all care unrelated to the terminal illness until
the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for laboratory services provided on October 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter (K0880).

You asked the Plan to pre-approve a power scooter. You say that you need this. The Plan denied your request. The Plan says sufficient documentation has not been received.

The Plan must follow Medicare rules. Medicare rules say that Power Mobility Devices (PMDs) require a standard written order prior to delivery, a report of a face-to-face encounter, and a written report of a home evaluation. 

We looked at the file and Medicare rules. The required documentation has not been submitted. Based on this information, we decided that Medicare rules for coverage of a power scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter (K0880).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Anastrozole.

You asked the Plan to pre-approve Anastrozole. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.

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-approve Anastrozole.

Benefits for Anastrozole may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 these services are medically necessary. The Plan denied your request. The Plan says that you do not require complex daily nursing care that must be provided in a skilled nursing facility. 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: 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 the enrollee has been referred to LTACH for complex medical management with treatment from trained clinical staff along with an interdisciplinary treatment team. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met.

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 indicating medical necessity for the requested LTACH services. 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myrbetriq.

You asked the Plan to pre-approve Myrbetriq. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.

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-approve Myrbetriq.

Benefits for Myrbetriq may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor (CGM).
You asked the Plan to pre-approve therapeutic CGM. You say that you have been diagnosed as a diabetic for 15 year and this device is the first improvement you have ever seen since. The Plan denied your request. The Plan says you do not meet the Medicare criteria for a therapeutic CGM.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction testing (92015) provided on March 5, 2021.
You asked the Plan to pay for the refraction testing. You say that you have gone to this provider in the past, and they were always in-network. You feel it should be covered as it was before. The Plan denied your request. The Plan says this provider is out-of-network; however, it was decided to pay for the covered services due to the misunderstanding. The refraction remains denied as you do not have routine vision benefits with the Plan, and this is a routine vision service.
The Plan must follow Medicare rules. The rules say that Medicare does not cover refractive testing. Though this service may have been appropriate, it is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the refraction testing (92015) provided on March 5, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (S1015, S8301) provided January 28, 2021.
You asked the Plan to pay for the home health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the codes billed are not eligible for payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code S1015 and S8301 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, the codes billed are marked with a status of "I" which means they are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met.
Therefore, we decided that the Plan does not have to pay for home health services (S1015, S8301) provided January 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) for teeth 8, 9, 10 and 11 provided March 4, 2021.
You asked the Plan to pay for the 4 additional tooth extraction. You say that you feel you were charged for more teeth than were extracted. The Plan denied your request. The Plan says coverage was previously provided for the first three tooth extractions according to your dental benefits. The four additional extractions are not covered because you have exceeded the frequency limit for this service. The Plan also states that there is no record that any additional extractions have been billed by the provider at the time of their review.
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. The Plan covers three tooth extractions per calendar year. We looked at the file and Medicare rules. The Plan submitted documentation that coverage was provided for the tooth extractions for teeth 3, 5, and 7 performed March 4, 2021. The extractions for these same teeth were submitted to the Plan again along with 4 additional extractions. The extractions for teeth 3, 5, and 7 were denied on this second claim only as duplicates and the Explanation of Benefits (EOB) explains that you are not responsible for the cost for these duplicate services listed. The four additional extractions for teeth 8, 9, 10, and 11 have exceeded the Plan's frequency limit of 3 extractions per calendar year and therefore are not covered. The Proposed Treatment Plan document included in the case file which lists 16 tooth extractions is an estimate for proposed services and is not a bill for services performed. Based on this information, we decided that the Plan's rules for coverage of the 4 additional tooth extraction have not been met. Therefore, we decided that the Plan does not have to pay for the extractions, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) for teeth 8, 9, 10 and 11 provided March 4, 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 this is medically necessary. The Plan denied your request. The Plan says there are no complex nursing or medical needs requiring a resource intensive inpatient hospital setting.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for knee pain and swelling after recent knee replacement surgery. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the mandibular partial denture - cast metal framework with resin denture bases (D5214) received March 1, 2021.
You asked the Plan to pay for the mandibular partial denture. You say that the Plan should cover the requested service. The Plan denied your request. The Plan says the requested services are not covered under your supplemental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the mandibular partial denture - cast metal framework with resin denture bases (D5214) received March 1, 2021.