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

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the stay at the SNF just to train for bed positioning and seated balance cannot be covered.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on November 8, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.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 inan 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 fora lumbar-sacral orthosis (L0650) provided to the enrollee on November 8, 2019.
Appeal type: Home Health
Decision: Partially Favorable

We decided that the Plan has to pay forOON home health services provided from January 9, 2019 to January 28, 2019. We decided that the Plan does not have to pay forOON home health services provided from January 29, 2019 to March 9, 2019. You asked the Plan to pay forOON home health services provided from January 9, 2019 to January 28, 2019. You say that this should be covered because the Plan authorized these services for a different date range.The Plan says that these dates of service were not authorized.We decided that the Planhas to pay forOON home health services provided from January 9, 2019 to January 28, 2019. 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 record shows that the Plan authorized services from this provider from December 28, 2018 to January 28, 2019. These services are within the approved date range. Therefore, we decided that the Plan has to pay forOON home health services provided from January 9, 2019 to January 28, 2019. We also decided that the Plandoes not have to pay forOON home health services provided from January 29, 2019 to March 9, 2019.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. 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. The authorization the Plan issued was for services from December 28, 2018 to January 28, 2019. These services were not provided within the authorized date range. Therefore, we decided that the Plan does not have to pay forOON home health services provided from January 29, 2019 to March 9, 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-approvea raised toilet seat.You asked the Plan to pre-approvea raised toilet seat. You say that you have severe arthritis. You say that you need the requested raised toilet seat because currently you are unable to stand when seated.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat may be appropriate for you, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approvea raised toilet seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you need the requested orthotics because you have ulcers on the bottom of your foot since May of 2019. You say that you were told the orthotics could make you more comfortable as it is very hard for you to walk right now. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion Spacer (22869 and 22870).
You asked the Plan to pre-approve the Superion Spacer. You say that the spacer is medically necessary for
treatment of the member's condition. The Plan denied your request. The Plan says there is a lack of evidence to
support that interspinous spacer devices are as safe and effective as the gold standard of surgical
decompression
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 Superion Spacer. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the spacer is experimental and more research is needed.
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 Superion Spacer have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Superion Spacer (22869 and 22870).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthrodesis (22633).
You asked the Plan to pre-approve the arthrodesis. You say that the member has had 11 years of pain despite appropriate conservative treatment. The Plan denied your request. The Plan says there is a lack of correlative imaging findings to support spinal fusion.
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 arthrodesis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of instability, fracture or lesion and criteria for fusion have not been met. 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 arthrodesis have not been met. Therefore, we decided that the Plan does not have to pre-approve arthrodesis (22633).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar sympathetic block (64520 and 01992).
You asked the Plan to pre-approve the lumbar sympathetic block. You say that the member has CRPS and would like to go forward with this injection. The Plan denied your request. The Plan says without sympathetic nervous system involvement, injections near the sympathetic nerve pathways would not be indicated.
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 lumbar sympathetic block. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the member does not have the signs and symptoms which would correlate with the diagnosis of CRPS. 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 lumbar sympathetic block have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar sympathetic block (64520 and 01992).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay foran ambulance transport and mileage (A0427, A0425) provided November 27, 2019.You asked the Plan to pay forthe ambulance services. You say that the services were medically necessary.The Plan denied your request. The Plan says the ambulance transport was not medically necessary.Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 ambulance services. Our reviewer says that rules for coverage were not met. Our physician reviewer found the enrollee reported severeright sided abdominal pain. Vital signs were stable and nothing was found on physical exam. There was no analgesia or advanced level care provided enroute. The enrollee could have safely been transported to the hospital by other means.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 ambulance services have not been met.Therefore, we decided that the Plan does not have to pay foran ambulance transport and mileage (A0427, A0425) provided November 27, 2019 .
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan denied your request. The Plan says the service is a covered benefit, but the enrollee has exceeded the benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation up to 48 one-way trips per year. We looked at your request, the records in the case file, and the rules. Requesting more trips than what it allotted is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.You asked the Plan to pre-approve the admission. You say that this is medically necessary.The Plan denied your request. The Plan says needs can be met at a lower level of 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does 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 admission have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto tablets.
You asked the Plan to pre-approve self-administered drugs. You say that this medication is needed to improve the enrollee's condition. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B.
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 Entresto tablets.
Benefits for self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedental extractions.You asked the Planto pre-approvethe extractions. You say that this is medically necessary.The Plandenied your request. The PlansaysMedicare will pay for dental services if they are an integral part of either a covered procedure, or extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plandoes not haveto pre-approvedental extractions.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the 4 additional fillings (D2391) provided on October 17, 2019.
You asked the Plan to reimburse you for 4 additional fillings. You say that the provider's office advised your fillings were covered at 100%. You say you were charged for 5 fillings. You say that you were charged for the filling on tooth # 17 twice. You also say that you were overcharged for the services that you received. The Plan denied your request. The Plan says 1 filling per calendar year is covered. The Plan says benefit limit has been exceeded.
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 and fillings are a covered service, the benefit limit of 1 filling per calendar year has been exceeded. The record shows that the Plan paid for 1 filling that you received on October 17, 2019. Additionally, the record shows that the 2 fillings billed for tooth # 17 were for different surfaces. Therefore, we decided that the Plan does not have to reimburse you for the 4 additional fillings (D2391) provided on October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on November 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you believe this was denied in error. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for lab work provided on November 19, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forCPT code 95999 provided on September 3, 2019.You asked the Plan to pay forCPT code 95999. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan saysCPT code 95999 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 95999 is unlisted neurological or neuromuscular diagnostic procedure.We find that CPT code 95999 is not supported in the medical record. Specifically, the record shows that train of four testing was performed and this is not the appropriate code for thisservice. Per Medicare guidelines, it is inappropriate to bill unlisted neurological or neuromuscular diagnostic CPT codes for train of four monitoring. There is no separate code for train of four monitoring. Based on this information, we decided that Medicare rules for coverage of CPT code 95999 have not been met.Therefore, we decided that the Plan does not have to pay forCPT code 95999 provided on September 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Alimta (pemetrexed) in combination with bevacizumab
and pembrolizumab.
You asked the Plan to pre-approve the requested combination therapy. You say that it is felt that this should be
approved. The Plan denied your request. The Plan says the use of this combination therapy for the enrollee's
condition is not supported as safe or effective.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
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 the requested combination therapy. Our
reviewer says that the documentation does not support that the requested treatment is medically reasonable and
necessary. Our physician reviewer found this review relates to a request for Alimta to be given in combination
with Bevacizumab and Pembrolizumab (Keytruda) to treat relapsed, metastatic adenocarcinoma of the lung, a
type of non-small cell lung cancer (NSCLC). The requested combination is not FDA approved for this
indication. The requested combination is not supported in any of the CMS approved compendia. This reviewer
did not find any supporting citations in a PubMed search.
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 combination therapy have not been met. Therefore, we decided
that the Plan does not have to pre-approve Alimta (pemetrexed) in combination with bevacizumab and
pembrolizumab.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aimovig auto-injector.You asked the Plan to pre-approve self-administered drugs. You say that you are appealing.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B.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 Aimovig auto-injector.Benefits for self-administered drugs 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ablation of the tongue base.
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says this is not medically necessary.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has mild sleep apnea with an AHI of 5 on sleep study dated July 18, 2019. He has not failed first line treatment with CPAP or an oral appliance. The record states he is not interested in these options. The reason for not trying CPAP is severe claustrophobia and the reason for not trying and oral appliance is personal preference. Because first line therapy has not been adequately used to treat the mild OSA, the requested radiofrequency ablation of the base of the tongue is not 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 the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve ablation of the tongue base.