Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.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 enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on April 7, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the services was not filed until April 8, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay for the services provided on April 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Losartan Potassium 25mg tab.
You asked the Plan to pre-approve Losartan Potassium 25mg tab. You say that the requested medication is
necessary. The Plan denied your request. The Plan says you have a medical only policy which does not include
Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Losartan Potassium 25mg
tab.
Benefits for Losartan Potassium 25mg tab 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 Plan does not have to pre-approve complete lower dentures (D5120).
You asked the Plan to pre-approve complete lower dentures. You say that the item is necessary in order for you to be able to eat properly. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one set of dentures (full, partial, immediate) every 5 years. We looked at the file and Medicare rules. The Plan covers a complete lower denture once every five years. The record shows that you received a lower denture on February 22, 2017. This means that you are not eligible for health plan coverage of a complete lower denture at this time. Based on this information, we decided that the Plan's rules for coverage of complete lower dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve complete lower dentures (D5120).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Transcatheter mitral valve replacement (TMVR)
procedure, associated Sapien 3 Lampoon procedure and hospital inpatient admission.
You asked the Plan to pre-approve a TMVR procedure. You say that the requested TMVR procedure is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the
requested Transcatheter mitral valve replacement (TMVR) procedure, associated Sapien 3 Lampoon procedure
and hospital inpatient admission.
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 a TMVR procedure. Our reviewer says
that the enrollee does not meet criteria for the requested Transcatheter mitral valve replacement (TMVR)
procedure, associated Sapien 3 Lampoon procedure and hospital inpatient admission. Our physician reviewer
found the enrollee is with a history of hypertension, hyperlipidemia, chronic kidney disease, aortic valve
replacement, alcohol septal ablation and pacemaker placement. A clinic note dated 06/29/2020 documents
edema, fatigue, dyspnea and severe mitral stenosis with a mean mitral gradient of 14mmHg.
Based on the records the enrollee has severe mitral stenosis being considered for transcatheter mitral valve
replacement. Standard treatment in this circumstance includes balloon mitral valvuloplasty or surgical mitral
valve replacement. The documentation does not support that the enrollee is not eligible or prohibitively high
risk for either of the above two procedures. Transcatheter mitral valve replacement is investigational and not
considered standard accepted practice for treatment of rheumatic mitral stenosis that is described in this
enrollee. Coverage criteria are not 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 a TMVR procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve a Transcatheter mitral valve replacement (TMVR) procedure, associated Sapien 3
Lampoon procedure and hospital inpatient admission.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on August 31, 2019.You asked the Plan to pay for laboratory services. You say that the tests were medically necessary. You say that the claim should be reimbursed in full.The Plan denied your request. The Plan says Original Medicare is responsible for payment.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for laboratory services provided on August 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on April 9, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe office visit (99202) and biopsy (11102). You say that you would like reconsideration because you did not know this provider was not in the Plan's network and you took the first appointment you could get.The Plan denied your request. The Plan says this provider is not a participating provider with the Plan and there was no authorization on file for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says thatthe 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 forthe medical services provided on April 9, 2020 by an out of network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the provision of INR test materials rendered on January 20, 2020 to February 9, 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 the services are not covered.
The Plan must follow Medicare rules. The rules say that procedure code G0249 shall not be allowed more frequently than once every four weeks. We looked at the file and Medicare rules. The file shows that the Plan previously paid for this code fewer than four weeks from the date of service at issue. 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 provision of INR test materials rendered on January 20, 2020 to February 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe duplex scan services provided on February 13, 2020.You asked the Plan to pay forthe duplex scan services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services are not a covered benefit.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The duplex scan services at issue in this appeal were requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe duplex scan services provided on February 13, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the staff-assisted home dialysis services provided from July 1, 2019 to December 31, 2019. We decided that the Plan does not have to pay for the staff-assisted home dialysis services provided from January 1, 2019 to March 31, 2019 and from January 1, 2020 to March 31, 2020..
You asked the Plan to pay for the staff-assisted home dialysis services provided from July 1, 2019 to December 31, 2019. You say that it is understood that this is not a Medicare-covered service but that is why authorization was requested and approved by the plan. As such, the plan should cover these services. The Plan says that this denial is correct.
We decided that the Plan has to pay for the staff-assisted home dialysis services provided from July 1, 2019 to December 31, 2019.
The Plan follows Medicare rules. Medicare rules say that the Plan must cover services which were approved. In this case, although these services may not be covered by Medicare, the Plan issued authorizations for these services for these dates. These authorization were specifically for the billed code and the Plan cannot reverse its decision to cover these codes retrospectively. Therefore, we decided that the Plan has to pay for the staff-assisted home dialysis services provided from July 1, 2019 to December 31, 2019.
We also decided that the Plan does not have to pay for the staff-assisted home dialysis services provided from January 1, 2019 to March 31, 2019 and from January 1, 2020 to March 31, 2020.
The Plan follows Medicare rules. Medicare rules say that the staff-assisted home dialysis services are not covered by Medicare. As these services are not covered by Medicare, the Plan has no obligation to make payment for services when there was no approval. The file does not show approval for services provided before April 1, 2019 or after December 31, 2019. As such, we find that rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the staff-assisted home dialysis services provided from January 1, 2019 to March 31, 2019 and from January 1, 2020 to March 31, 2020..
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 the powered upper extremity range of motion assist device (L8702).
You asked the Plan to pre-approve the myoelectric device. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says this item does not meet the criteria of durable medical equipment and is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the powered upper extremity range of motion assist device (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on March 12, 2020 by an out of network (OON) provider.
You asked the Plan to pay for podiatry services. You say that these services were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained. The plan says that the member's primary care physician did not refer 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 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 podiatry services provided on March 12, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea core build-up (D2950).You asked the Plan to pre-approvea core build-up. You say that the service is medically necessary.The Plan denied your request. The Plan says a Core Build-up is not a covered benefit under the plan or Medicare.Medicare generally does not cover dental services. However, the Plan offers adental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea core build-up (D2950).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 17, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 and the referring provider are not network providers with the Plan. The Plan did not pre-approve the laboratory services. 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 laboratory services provided on December 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Guardant360 panel rendered on February 25, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure code 81479.The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 forthe Guardant360 panel rendered on February 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex interspinous spacer for the enrollee.You asked the Plan to pre-approve the spacer. You say that this is medically necessary.The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of the health problem.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 spacer. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer remains experimental. 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 spacer have not been met.Therefore, we decided that the Plan does not have to pre-approve the Vertiflex interspinous spacer for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel One.
You asked the Plan to pre-approve Gel One. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
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 Gel One. Our reviewer says that the
documentation does not support that the requested drug, Gel One is medically reasonable or necessary. Our
physician reviewer found you have pain related to osteoarthritis of the right knee, confirmed with imaging
studies. You have failed conservative treatment. The documentation does not support that you have tried
Monovisc and Orthovisc. The documentation does not support that Monovisc and Orthovisc would likely be
less effective and/or likely have adverse effects. Therefore, you do not meet criteria for the requested drug.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Gel One have not been met. Therefore, we decided that the Plan does not have
to pre-approve Gel One.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra eye drops.
You asked the Plan to pre-approve Xiidra eye drops. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered 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 Xiidra eye drops.
Benefits for Xiidra eye drops 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 a sclerosant injection (36466).
You asked the Plan to pre-approve a sclerosant injection. You say that the enrollee needs this service. The Plan
denied your request. The Plan says the record does not show the enrollee has tried conservative treatment.
The Plan must follow Medicare rules. Medicare rules say that surgical treatment of varicose veins or
sclerotherapy is indicated when a 3-month trial of conservative therapy such as exercise, periodic leg elevation,
weight loss, compressive therapy, and avoidance of prolonged immobility where appropriate, has failed.
We looked at the file and Medicare rules. The submitted medical records do not document a 3-month trial of
conservative therapy. Based on this information, we decided that Medicare rules for coverage of a sclerosant
injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a sclerosant
injection (36466).