Persius/hicric huggingface dataset:
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 this is prescribed from my doctor as medically necessary. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3 transport trips to the requested dental office.
You asked the Plan to pre-approve the transportation services. You say that going to this dental provider is medically necessary. You say that you are in the middle of your treatment plan. The Plan denied your request. The Plan says the requested trips to a dental provider are outside of the usual service radius of 30 miles.
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 when trips are within 30 miles from pick-up point to destination point in Pennsylvania.
We looked at your request, the records in the case file, and the rules. Specifically, the requested destination is 105 miles away which well exceeded the 30-mile radius 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 3 transport trips to the requested dental office.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).
You asked the Plan to pre-approve the special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs). The Plan denied your request. The Plan says the certification May 3, 2021 documents the enrollee has none of the qualifying diagnoses, does not require intense care coordination, and has no high risk for hospitalizations or high risk for adverse health outcomes.
The Plan contract says that, in order to be eligible for special supplemental benefits for the chronically ill, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. We looked at the file and Medicare rules. The file shows that your medical conditions are not eligible medical conditions under the Plan's benefit. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (D3330) for tooth #14.
You asked the Plan to pre-approve endodontic therapy. You say that this service is necessary. The Plan denied your request. The Plan says this service is not covered by the Plan's dental 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. The Plan does not cover endodontic services. 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 pre-approve endodontic therapy (D3330) for tooth #14.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-network
provider.

You asked the Plan to pre-approve physical therapy to be provided by the requested out-of-network provider.
You say that your spouse received physical therapy at the facility, and you would not have to make separate
trips for your care. You say that where you currently are receiving physical therapy is poorly ventilated and the
level of care is subpar. The Plan denied your request. The Plan says with limited exceptions, while a member of
the Plan, you must use network providers to get medical care and services. The only exceptions are
emergencies, urgently needed care when the network is not available (generally, when the member is out of the
area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers.

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 physical
therapy to be provided by the requested out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Linzess oral capsule.

You asked the Plan to pre-approve Linzess oral capsule. You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B benefit.

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 Linzess oral capsule.

Benefits for Linzess oral capsule 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing services to be provided by an out of
network (OON) provider.

You asked the Plan to pre-approve skilled nursing services. You say that you would like these services
provided by an out-of-network provider. The Plan denied your request. The Plan says there are in-network
providers available for these services.

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-approve
skilled nursing services to be provided by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mental health services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve OON mental health services. You say that this is medically necessary. The Plan denied your request. The Plan says this is available in-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 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-approve mental health services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network neurologist.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says this service can be provided in-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 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-approve a referral to an out-of-network neurologist.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the visual field examination described by current procedural terminology (CPT) code 92081 provided on July 28, 2020.

You asked the Plan to pay for CPT code 92081. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 92081.

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 92081 is Visual field examination, unilateral or bilateral, with interpretation and report; limited examination (eg, tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus 3 or 7 equivalent). 

We find that CPT code 92081 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of Visual field examination, unilateral or bilateral, with interpretation and report; limited examination (e.g., tangent screen, Autoplot, arc perimeter or single stimulus level automated test, such as Octopus 3 or 7 equivalent). Based on this information, we decided that Medicare rules for coverage of CPT code 92081 have not been met. Therefore, we decided that the Plan does not have to pay for the visual field examination described by current procedural terminology (CPT) code 92081 provided on July 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve test for detecting genes associated with cancer of body organ (CPT code 81445), for the enrollee.

You asked the Plan to pre-approve the testing. You say that the services are medically necessary. The Plan denied your request. The Plan says the request is covered ONLY for Non-Small Cell Lung Cancer (NSCLC) or Metastatic Colorectal Cancer (mCRC)-which the enrollee has neither. The Plan states the provider would like genetic testing on this enrollee because cell-free DNA showed the enrollee has a genetic alteration for which there is a clinical trial of targeted therapy and the provider waned to confirm the alteration is in tumor and that there is no other competing mutation that would make the enrollee less likely to respond to targeted therapy. The Plan states there was not support for the specific test for the enrollee's diagnosis.

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 physician reviewer found the case file does not contain documentation demonstrating that the enrollee in this case has a covered diagnosis for a genomic sequence analysis panel, such as non-small cell lung cancer, or metastatic colorectal cancer. 

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 not been met. Therefore, we decided that the Plan does not have to pre-approve test for detecting genes associated with cancer of body organ (CPT code 81445), for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergency air ambulance transport (CPT code(s): A0434, A0430, A0435, A0426), for the enrollee.

You asked the Plan to pre-approve non-emergency air ambulance transport. You say that the enrollee cannot tolerate a seven (7) hour trip via ground transport due to pain/spasm/risk for skin breakdown. You state the enrollee is currently 7 hours aware from home, needs to be transported home to be near family as the enrollee will most likely be long term in skilled facility. The Plan denied your request. The Plan says the request does not meet medical necessity as the request appears to be non-urgent in nature and the enrollee's medical condition does not require an immediate or rapid ambulance transportation to the skilled nursing facility in the home state. The Plan states air ambulance services are not covered for transport to a nursing facility per the CMS guidance.

The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate.

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 non-emergency air ambulance transport. Our physician reviewer found the review indicates that currently, the enrollee is dependent for transfers using a lift and there are concerns that the enrollee may not tolerate 7 hours of ground transport due to pain, spasm, and/or risk of skin breakdown. The request does not meet medical necessity as the request appears to be non-urgent in nature and the enrollee's medical condition does not require an immediate or rapid ambulance transportation to the skilled nursing facility in the home state. Furthermore, air ambulance services are not covered for transport to a nursing facility per the CMS guidance. The review has determined that the documentation supports that the enrollee suffers from an illness or injury that contraindicates transportation by any means other than ambulance. The documentation does not support that the enrollee's condition was such that the time needed to transport a enrollee by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health. The documentation did not support that the transferring hospital did not have adequate facilities to provide the medical services needed by 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 non-emergency air ambulance transport have not been met. Therefore, we decided that the Plan does not have to pre-approve non-emergency air ambulance transport (CPT code(s): A0434, A0430, A0435, A0426), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental
pneumatic appliance (E0667).

You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that in
consideration of this enrollee's unique clinical condition which has failed to respond effectively to conservative
therapies or a basic device, you ask reversal of the denial. The Plan denied your request. The Plan says the
enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial
of a basic pneumatic compression device of either E0650 or E0651 or that the enrollee has edema on the
abdomen, trunk or chest wall.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device
(E0652) and segmental pneumatic appliance (E0667).
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 IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.
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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary
approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF 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-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current level of care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 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 delirium and right knee pain after a recent total knee replacement surgery. Medical conditions 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. The enrollee 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 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 IRF admission and services.