Persius/hicric huggingface dataset:
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 you would like the plan to reconsider their denial The Plan denied your request. The Plan says the requested admission 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 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 the enrollee is medically stable. The enrollee required minimal assistance with walking 60 feet with a rolling walker and transfers. The enrollee required moderate to maximum assistance for activities of daily living with poor balance and poor endurance. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. The enrollee may benefit from further skilled physical therapy and occupational therapy but does not require treatment in an IRF. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee requires aggressive therapy, and close physician monitoring of mental status.The Plan denied your request. The Plan says the enrollee does not need to be seen by a specialized rehab physician, or have complex rehab needs.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 askedour 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 has a diagnosis of Encephalopathy, unspecified. Her past medical history is notable for diabetes, hypertension, and chronic kidney disease. The enrollee was admitted to the hospital with increasing weakness and confusion. She is being treated for a urinary tract infection. She is currently medically stable. There is no evidence of complex medical issues that require monitoring by an inpatient rehabilitation physician three times per week or acute rehab nursing care. While the enrollee may benefit from continuing speech, physical, and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head rendered on
February 10, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 70450 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 70450 and 70496. Code 70450 is a column II code with a
modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate
modifier to allow for separate payment.
Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head
rendered on February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on January 29, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on January 29, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia.You asked the Plan to pre-approveProlia. The Plan denied your request. The Plan says the enrollee must have a history of osteoporotic fracture; or has had previous treatment, contraindication, or intolerance to Zoledronic acid.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 physician reviewer found that the enrollee has age-related osteoporosis without current pathological fracture. It is documented that the enrollee was unsure if she ever took alendronate. The Plan requires a trial of Zoledronic acid or a history of osteoporotic fracture before they will approve the requested drug. The documentation does not show that the plan requirements have been met. The documentation does not support that Zoledronic acid would likely be less effective, 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approveProlia.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay fora chest x-ray (71045) provided on October 31, 2019.You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because this service was denied as a duplicate in error.The Plan denied your request. The Plan says that the submitted documentation supports 1 (one) unit of 71045-26, which was previously approved/paid.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 71045 is supported in the record. Specifically, the record indicates that this services was rendered by the appealing provider. The x-ray that was approved was paid to a different provider. This is not a duplicate claim. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have been met.Therefore, we decided that the Plan has to pay fora chest x-ray (71045) provided on October 31, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you are currently under treatment for pain in
your hip and knee. You say that you are unable to stand and walk without a walker or a cane. You stated that
you cannot stand in the bathtub to shower because you may lose your balance and fall. The Plan denied your
request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand orthosis provided on November 1, 2019.
You asked the Plan to pay for the wrist hand orthosis (L3916). You say that the orthosis was medically
necessary. The Plan denied your request. The Plan says rules for telehealth services have not been met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the wrist hand orthosis
provided on November 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveincontinence supplies.You asked the Plan to pre-approveincontinence supplies. You say that you have had bladder surgery that did not take. You say that you are in a personal care home and you cannot get up at night without the help of an aide. You stated that you cannot get up fast enough to go to the bathroom and you are unable to hold your urine. You say that you have several medical conditions which cause you constant problems and you are always having to go to the bathroom. You asked the Plan to reconsider their denial and provide coverage of the requested incontinence supplies. You say that they are necessary for you and you have to wear them for your medical problems.The Plan denied your request. The Plan says these items are not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies arenot covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approveincontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a thoracic spinal cord stimulator (SCS) trial.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan
denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that neuromstimulator implants are covered when
specific criteria are met.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has chronic neck and low
back pain. She has had a cervical laminectomy and has cervical radiculopathy. She had a cervical SCS trial
which gave her 75 percent pain relief. She has not had any lumbar spine surgery, medial branch blocks, or
documentation of complex regional pain syndrome. There is no documented peripheral arterial disease. She has
not had a psychological or psychiatric evaluation. The criteria for the SCS trial are not met and the services are
not reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a thoracic spinal cord stimulator (SCS) trial.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiography provided on January 2, 2020.You asked the Plan to waive the copayment for the echocardiography. You say that you previously paid less. You say that the copayment is wrong.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 copayment for each Medicare-covered radiological diagnostic service. You have been asked to pay a $110 copayment for the echocardiography. The echocardiography falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the echocardiography provided on January 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient psychiatric services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethese OON services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services can be provided by a network provider.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approveinpatient psychiatric services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies (A4520).
You asked the Plan to pre-approve the incontinence supplies. You say that incontinence supplies are medically
necessary for the enrollee. The Plan denied your request. The Plan says incontinence supplies are not a covered
benefit by Medicare or the health plan.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate for the enrollee in this case, neither the Plan nor Medicare
offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence
supplies (A4520).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the seat lift mechanism of a seat lift chair.
You asked the Plan to pre-approve the seat lift mechanism of a seat lift chair. You say that the enrollee cannot
sleep lying flat. The Plan denied your request. The Plan says the enrollee does not meet the requirements.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions
listed above are met.
We looked at the file and Medicare rules. There is no documentation of the chair being a course of treatment
for arthritis of the hip or knee, or severe neuromuscular disease. Based on this information, we decided that
Medicare rules for coverage of a seat lift chair have not been met. Therefore, we decided that the Plan does not
have to pre-approve the seat lift mechanism of a seat lift chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis, bitewings, periodic oral evaluation, and oral hygiene instructions provided on February 24, 2020 by an OON provider. You asked the Plan to pay for the prophylaxis, bitewings, periodic oral evaluation, and oral hygiene instructions. You say that in the past, this provider was participating with your plan. You also say that the Plan's website lists this provider as a participating provider. The Plan denied your request. The Plan says these services were rendered by an OON provider. 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, you are responsible for the difference between the billed amount and allowed amount for services received by an OON provider. Therefore, we decided that the Plan does not have to pay for the prophylaxis, bitewings, periodic oral evaluation, and oral hygiene instructions provided on February 24, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says out-of-network
services are not approved unless they are not available in-network or are emergent.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the
requested physician's services.
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 the SNF services. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says the enrollee does not have any skilled nursing needs. The Plan says that the enrollee's current level of function shows that daily skilled therapy is not needed.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and had a stage II pressure ulcer to her coccyx and right heel. The enrollee received physical therapy, speech therapy, and occupational therapy. The enrollee was at a moderate to maximal assist/dependence with bed mobility and transfers. The enrollee remained non-ambulatory. The enrollee required varying assist with activities of daily living. The enrollee was to work with a speech therapist for cognition/communication to enhance short term memory. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the portable oxygen concentrator.You asked the Plan to reimburse you for the portable oxygen concentrator. You say that you were away and needed portable oxygen.The Plan denied your request. The Plan says payment is not made for purchases of oxygen equipment.The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Medicare rules say that only rented oxygen equipment is eligible for coverage.We looked at the file and Medicare rules. Purchased oxygen equipment is statutorily non-covered by Medicare.Based on this information, we decided that Medicare rules for coverage of the portable oxygen concentrator have not been met.Therefore, we decided that the Plan does not have to reimburse you for the portable oxygen concentrator purchased on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One. You asked the Plan to pre-approve the Synvisc-One. You say that Synvisc-One is medically necessary and should be approved. The Plan denied your request. The Plan says they did not receive documentation supporting the medical necessity for a step therapy exception. 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 Synvisc-One. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the provided records and physician's statement did not show evidence of the patient having tried and failed or have a contraindication to Monovisc or Orthovisc. there was no evidence to show that using Synvisc-One would be superior in effectiveness or safety to the patient than Monovisc or Orthovisc which are essentially equivalent in terms of safety and effectiveness. She had tolerated Orthovisc in the past but there was no mention of a trial of Monovisc. There is no current evidence suggesting one viscosupplemental injection for osteoarthritis is significantly more effective than another. 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 Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.