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 disagree with the denial. The Plan denied your request. The Plan says the services are 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 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 medically necessary. Our physician reviewer found that you were admitted to the hospital on May 18, 2021 and underwent surgery on May 21, 2021. The therapy notes state you need assistance with walking 75 feet using a rolling walker. The records do not show that you require the intensity of services in an IRF. You do not require 15 hours per week of rehabilitative services and regular physician evaluation. 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 complete series x-ray (D0210), and the 2D oral or facial
photographic images (D0350 x 4) provided on December 23, 2020.
You asked the Plan to pay for the dental services. You say that you contacted the dental office prior to your
appointment to verify your benefits. You say that you were advised it had already been done. You say that you
told them you did not want any services that your insurance would not cover. You say that you cannot afford to
pay for anything that insurance would not cover. You also say that you were advised that a pre-determination
had been sent, but you did not receive one. The Plan denied your request. The Plan says 1 panoramic x-ray or 1
full mouth x-ray is covered every 5 years. The Plan says that the frequency limit for this service has been
exceeded. The Plan also says that 2D oral or facial photographic images are not listed as covered services.
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 full mouth x-ray is listed as a
covered service, the frequency limit has been exceeded. The record shows that the Plan paid for the panoramic
x-ray provided on the date of service in this case. Additionally, 2D oral or facial photographic images are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
complete series x-ray (D0210), and the 2D oral or facial photographic images (D0350 x 4) provided on
December 23, 2020.
Your complaint about not receiving an pre-determination for the services is not a valid appeal for medical
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not
permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for routine transportation trips provided from August 17, 2020,
through December 30, 2020.

You asked the Plan to pay for the routine transportation trips. The Plan denied your request. The Plan says you
have exhausted your transportation benefit for the 2020 plan year.

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 a maximum of 50 one-way trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pay for routine transportation trips provided from August 17, 2020,
through December 30, 2020
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fifteen (15) additional OT visits.

You asked the Plan to pre-approve the fifteen (15) additional OT visits. The Plan denied your request. The Plan says that additional OT does not meet medical necessity criteria.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 fifteen (15) additional OT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been instructed in home safety. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 

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 fifteen (15) additional OT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve fifteen (15) additional OT visits.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve genetic testing (COLARIS AP plus Myriad myRisk Update).

You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says that the records do not indicate a personal history of twenty or more adenomas.

The Plan must follow Medicare rules. Medicare provides coverage for APC and MUTYH gene testing for individuals suspected to have Familial Adenomatous Polyposis (FAP), Attenuated FAP (AFAP) or MYH-associated polyposis (MAP) with a personal history of 20 or more adenomas over a lifetime. 

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 testing. Our reviewer says that the requested testing is considered medically reasonable and necessary in this case. Our physician reviewer found that on the form for Myriad Colaris testing, you are listed as having 150 polpys over your lifetime. This would meet the criteria, in addition to your family history. 

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 testing have been met. Therefore, we decided that the Plan has to pre-approve genetic testing (COLARIS AP plus Myriad myRisk Update).

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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided on November 9, 2020, to
November 29, 2020 by an OON provider.

You asked the Plan to pay for the home health services. You say that you would like to appeal these services.
The Plan denied your request. The Plan says the services were rendered by a non-contracted provider. The Plan
also says that prior authorization was not obtained.

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
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the home health services provided on November 9, 2020, to November 29, 2020 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that the member's chance to return home and maintain living at home will be significantly reduced if his opportunity to participative in an acute rehab program is denied. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed, in other settings.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for respiratory failure and COVID 19 pneumonia. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a
Sanexas device reported on October 26, 2020.

You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You
say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan
says the record does not support that the procedures were performed as billed.

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 HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. 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. 

We find that CPT codes 97032, 97150, 97016, 96372, J3490, J3411, and J3415 are not supported in the medical record. Specifically, the record consists of a follow up from Sanexas treatment, with no mention of an injection or other procedure for this encounter. There is no procedure note or other documentation that supports that the services billed were performed. Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on October 26, 2020.
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 there is no need for daily skilled nursing care or daily physician oversight.
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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and has been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). The enrollee has tolerated inpatient rehab services and continues to improve with daily skilled nursing and/or skilled therapy services. There would be benefit from continued services at this level of care. The enrollee had made slow progress with therapy, and there is no indication that transfer to a skilled nursing facility is required. He can continue to receive skilled rehab services at the current IRF or be stepped down to a lower level of care when appropriate. There are no services offered at a SNF that are not offered at an inpatient rehab facility. Admission to a SNF for inpatient skilled rehab services 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says daily
skilled therapy is no longer needed.
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.
Continued SNF services beyond June 4, 2021, were requested. 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 continued services. Our physician reviewer found that at the time of admission, the
enrollee required skilled rehab services to improve function due to weakness and deconditioning. There were
no skilled nursing needs. The enrollee no longer requires any skilled nursing or rehab services on a daily basis.
She is not expected to make measurable gains within a reasonable period of time or require skilled therapy to
prevent deterioration with mobility or activities of daily living. The enrollee does not require skilled therapy to
establish a safe and effective maintenance program. As a practical matter, she does not require any skilled
services on an inpatient basis, at a SNF 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 continued services have not been met. Therefore, we decided that the Plan does
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail an oral bisphosphonate drug and zoledronic acid first.

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 Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is with osteoporosis, diagnosis confirmed with bone density testing. She also has a history of pancreatic cancer and has had a Whipple procedure. Records indicate that oral bisphosphonates are not recommended due to her prior stomach surgery and history of gastroesophageal reflux disease. Prolia injections have been requested. Based on the medical records provided there is concern that use of oral bisphosphonates may expose the enrollee to increased risk of adverse effects but there is no indication that zoledronic acid would likely be less effective and/or likely have adverse effects for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care provided on February 5, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the nursing facility care. You say that you were unable to obtain authorization because the enrollee had not seen her PCP recently and would like reconsideration of the claim. The Plan denied your request. The Plan says no prior authorization was obtained.
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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the nursing facility care provided on February 5, 2021 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for somatosensory testing provided on August 25, 2020 by an out of network provider.

You asked the Plan to pay for somatosensory testing (95938). You say that the records support the billing of procedures as medically necessary. The Plan denied your request. The Plan says the request is for payment on non-emergent services with no 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 somatosensory testing provided on August 25, 2020 by an out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided by an out-of-network
provider on December 10, 2020.

You asked the Plan to waive the copayment for ambulance services. You say that you cannot afford this and
would like the Plan to pay for this. The Plan denied your request. The Plan says the correct copayment has been
applied.

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 $280
copayment for ambulance services/ground ambulance.

You have been asked to pay a $280 copayment for ambulance services. The correct copayment has been
applied to the services that were provided. Ambulance services fall within the ambulance services/ground
ambulance 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 ambulance services
provided by a participating provider on December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical or manipulative therapy performed for
maintenance (S8990) provided October 12, 2020 to October 15, 2020.

You asked the Plan to pay for the chiropractic services. You say that you are requesting reconsideration for
denial of payment for the services you've received. The Plan denied your request. The Plan says S8990 is not a
valid code for Medicare Advantage plans.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the physical or manipulative therapy performed for maintenance (S8990) provided October 12, 2020 to October 15, 2020.