Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health aide or certified nurse assistant.

You asked the Plan to pay for the home health aide or certified nurse assistant. The Plan denied your request.
The Plan says you received home health aide services from a provider who is not under contract with the
Health Plan, and is not certified for Medicare.

The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items
or services, a provider or supplier must be enrolled in the Medicare program.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the home health aide or certified nurse assistant have not been met. This provider is not part of the
Medicare program and is not payable. Therefore, we decided that the Plan does not have to pay for the home
health aide or certified nurse assistant.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lorazepam (J8499).
You asked the Plan to pre-approve lorazepam. You say that the enrollee's anxiety will be controlled with this. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under 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 lorazepam (J8499).
Benefits for lorazepam 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF care. You say that an inpatient skilled nursing facility admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an inpatient skilled nursing facility admission.
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 SNF care. Our reviewer says that an inpatient skilled nursing facility admission is not medically necessary. Our physician reviewer found that you do not require skilled nursing or skilled therapy services on a daily basis. Additionally, as a practical matter, you do 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of care with an out of network (OON) ophthalmologist.
You asked the Plan to pre-approve the continuation of care with the OON ophthalmologist. You say that you want to prevent going blind. You say that it is urgent and emergent that you be able to continue your treatment with the OON provider. The Plan denied your request. The Plan says it is not medically necessary to receive the needed care with an OON provider. The Plan says that they are able to safely provide the requested services in-network.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 continuation of care with the OON ophthalmologist. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician reviewer found the enrollee has a diagnosis of bilateral severe primary open-angle glaucoma. On June 29, 2020, the OON ophthalmologist documents that the enrollee's intraocular pressure is back in the target range. Updating glaucoma testing with a new provider was planned. The documentation does not support that it is medically necessary for the enrollee in this case to continue care with the out-of-network provider. There is nothing unique about the enrollee's condition that would make it medically necessary for her to continue care with the OON provider.
The Plan has shown that they have in-network specialists who have the qualifications and expertise necessary to meet the current medical Standards of Care required for treatment of the enrollee's condition. The documentation supports that the enrollee's medical management and/or follow-up care be safely transitioned to an in-network specialist at this time. 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 continuation of care with the OON ophthalmologist have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of care with an out of network (OON) ophthalmologist.
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 the enrollee needs to move to the next level of care. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the TLACH that are not available at the acute care hospital where he is currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing for four or more teeth per quadrant represented by code D4341.
You asked the Plan to pre-approve the periodontal scaling and root planing services. You say that the periodontal scaling and root planing in dispute is medically necessary. The Plan denied your request. The Plan says the services in dispute are not medically necessary. The Plan says that the information provided did not demonstrate evidence of significant bone loss and/or radiographic root surface calculus on 4 or more teeth per quadrant.
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 periodontal scaling and root planing when the services are medically necessary and reasonable. 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 periodontal scaling and root planing services. Our reviewer says that the criteria for coverage of the requested code have not been met. Our physician reviewer found the request is for scaling and root planing four or more teeth on the upper left and right quadrants. The included periodontal charting indicates substantial pocketing in the upper right and left molars. The provided radiographs indicate bone loss in the areas of the upper molars but not beyond. There are only two teeth in each upper quadrant that show notable bone loss, despite other pocket readings that were taken. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the periodontal scaling and root planing services have not been met. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing for four or more teeth per quadrant represented by code D4341.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provided on July 21, 2020.
You asked the Plan to pay for the outpatient mental health services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior 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 did not pre-approve the services 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 outpatient mental health services provided on July 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from April 29, 2020, through May 1, 2020.
You asked the Plan to waive the copayment for the inpatient stay. You say that you were sent home before your pain was under control and was readmitted to the hospital two days later. You say that there should not have been a break in service, and you are appealing the charge. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $340 copayment per day, for days 1-5 for each inpatient stay. You have been asked to pay a $680 copayment for the inpatient stay. ($340/day x 2 days = $680). The inpatient stay falls within the "Inpatient hospital care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient stay provided from April 29, 2020, through May 1, 2020.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for weight loss and failure to thrive. Medical problems 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. There is no documented need for intensive rehabilitation services. 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. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
You asked the Plan to pre-approve the 10 additional physical therapy visits. You say that the enrollee has undergone extensive surgeries and hospitalizations leading to his de-compensation and overall loss of strength. You say that the enrollee has made some progress but is still requiring the unique skills of a physical therapist. You say that the enrollee needs further therapy to continue to improve his ambulation, pain and weakness. You say that therapy is necessary for the enrollee's health to improve and he needs to re-initiate services as soon as possible to ensure he does not physically decline. The Plan denied your request. The Plan says the clinical information provided does not support that the additional physical therapy in dispute is medically necessary.
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 10 additional physical therapy 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 based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for the patient's condition. Based on the available records the patient appears to have improved with therapy to the point of being able to manage his activities of daily living, but he has fatigue. Further formal therapy at this point does not appear to be likely to achieve any significant improvement in the patient's symptoms or functional status. Further utilization of the home exercise program appears appropriate at this point.
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 10 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (PWC) harness (E2313), expandable controller (E2377), electronic connection between wheelchair controller and two or more power seating system motors (E2311), and calf pads (K0108).
You asked the Plan to pre-approve a PWC harness, expandable controller, electronic connection between wheelchair controller and two or more power seating system motors, and calf pads. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a PWC harness, expandable controller, electronic connection between wheelchair controller and two or more power seating system motors, and calf pads. Our reviewer says that the items are not medically necessary. Our physician reviewer found the documentation does not support that there is a medical need to control the requested power options through a joystick. The enrollee should be able to control the power options using their own switches which are included with these power options. 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 PWC harness, expandable controller, electronic connection between wheelchair controller and two or more power seating system motors, and calf pads have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (PWC) harness (E2313), expandable controller (E2377), electronic connection between wheelchair controller and two or more power seating system motors (E2311), and calf pads (K0108).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on October 8, 2020. You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the submitted documentation did not contain a signed physician order. The Plan must follow Medicare rules. Medicare rules say that all diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. We looked at the file and the rules. In this case, there are insufficient medical records to show the intent of the testing that was provided. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on October 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical injection of Fluid Flow with imaging guidance.
You asked the Plan to pre-approve Fluid Flow. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this procedure is correct, because studies have not proven that the use of this product is helpful for the enrollee's condition.
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 Fluid Flow. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/investigational procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Fluid Flow have not been met. Therefore, we decided that the Plan does not have to pre-approve a surgical injection of Fluid Flow with imaging guidance.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a powered pressure-reducing air mattress (E0277) provided on September 16 to October 16, 2020.
You asked the Plan to pay for a powered pressure-reducing air mattress. You say that the enrollee is highly susceptible to pressure ulcers and needs the requested item. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a powered pressure-reducing air mattress (E0277) provided on September 16 to October 16, 2020.
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 these services. 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 Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has right elbow osteoarthritis. Gel-One is not FDA-approved for the treatment of osteoarthritis of the elbow nor has off-label support in Medicare-approved compendia. Gel-One is not shown to be safe and effective and is not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for bioimpedance spectroscopy (93702) provided on September
28, 2020.
You asked the Plan to pay for bioimpedance spectroscopy. You say that you would like reconsideration
because this is the standard of care to definitively diagnose the member. The Plan denied your request. The
Plan says technical component charges are institutional charges and not billed separately by physicians.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We find that CPT code 93702 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT
code 93702 has a PC/TC indicator of 3, meaning that it is a technical component only code. The technical
components of diagnostic services furnished to hospital outpatients are paid to the facility. Based on this
information, we decided that Medicare rules for coverage of bioimpedance spectroscopy have not been met.
Therefore, we decided that the Plan does not have to pay for bioimpedance spectroscopy (93702) provided on
September 28, 2020.