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

We decided that the Plan does not have to pre-approve SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because the SNF admission is medically necessary. The Plan denied your request. The Plan says the member does not have a need for skilled nursing or skilled therapy.
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 SNF admission. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found based on the medical records
provided this member does not require the services on an inpatient basis, only in a skilled nursing facility
setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does
not have to pre-approve SNF admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6534.
You asked the Plan to pre-approve the compression stockings. You say that you have trouble with your legs and was told that you had to have the stockings. The prescription is for 2 pairs but You just need 1 pair to help. The Plan denied your request. The Plan says these gradient compression stockings are non-covered under the surgical dressing benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6534 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6534.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient behavioral health services.
You asked the Plan to pre-approve inpatient services. The Plan denied your request. The Plan says medical
necessity has not been met.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 inpatient services. Our physician
reviewer found that the services were not reasonably expected to improve the enrollee's condition or for the
purpose of diagnosis. Based upon review the records the enrollee was not shown to be a danger to himself or
others. He was without agitation or aggression without perceptual disturbance including auditory or visual
hallucinations.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient services have not been met. Therefore, we decided that the Plan does
not have to pre-approve inpatient behavioral health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3 more months of continued use of the CPAP machine and heated humidifier.
You asked the Plan to pre-approve4 additional months continued use of the CPAP machine and heated humidifier. You say that the CPAP level was decreased and now the enrollee is more compliant. The Plan denied your request. The Plan says the download from the machine shows usage of 27% so they will approve only one month.
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. The record shows the enrollee is not compliant. Based on this information, we decided that Medicare rules for coverage of continued use of the CPAP machine and heated humidifier have not been met. Therefore, we decided that the Plan does not have to pre-approve 3 more months of continued use of the CPAP machine and heated humidifier.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve specialist provider office visits (99204, 99214) to be provided by
an out of network provider.
You asked the Plan to pre-approve specialist office visits. You say that the requested out of network provider is
a specialist in the field and that your case is difficult and sensitive. The Plan denied your request. The Plan says
that there are multiple in-network nephrology providers who can provide the requested 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.
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 specialist office visits. Our reviewer
says that the requested services are considered medically necessary in this case. Our physician reviewer found
that, while evaluation of adrenal pathology comes under the purview of nephrology, said service represents a
minute number of patients in their practice and often can go years without seeing a new consultation regarding
this problem. These evaluations can typically be done better at Tertiary Care centers as they have more
expertise in diagnosis and treatment. Consultation with the requested out of network provider is medically
reasonable and necessary for you.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of specialist office visits have been met. Therefore, we decided that the Plan has to
pre-approve specialist provider office visits (99204, 99214) to be provided by an out of network provider.
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: 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 enrollee would benefit from inpatient rehabilitation. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower 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 the enrollee does not require treatment by multiple therapies and an intensive rehabilitation therapy program. While the enrollee does require physical and occupational therapy, there is no
documented need for an intensive rehabilitation program. Medically necessary services can be provided in 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography angiography (CTA) scan of the abdomen 
and pelvis. 
 
You asked the Plan to pre-approve a CTA scan of the abdomen and pelvis. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 a CTA scan of the abdomen and pelvis. 
Our reviewer says that the services are medically necessary. Our physician reviewer found the request for a 6-
month follow up after endograft repair of a 5cmm abdominal aortic aneurysm (AAA) is reasonable. The notes 
indicate a 1-month follow up CTA was equivocal for leak although the report has not been included. In any 
case, a 6-month follow up CTA after endograft repair is reasonable and should be approved especially given an 
equivocal post op CTA report. 
 
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 CTA scan of the abdomen and pelvis have been met. Therefore, we decided 
that the Plan has to pre-approve a computed tomography angiography (CTA) scan of the abdomen and pelvis.  
 
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: 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services (97811, 97810, 97026) provided December 9, 2020.
You asked the Plan to pay for the acupuncture services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not rendered by a physician or under the supervision of a physician or other approved provider. The Plan must follow Medicare rules. The rules say that Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist. We looked at the file and Medicare rules. The services were provided by an acupuncturist and the record does not show the provider was supervised by a physician, physician assistant, or nurse practitioner/clinical nurse specialist. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Therefore, we decided that the Plan does not have to pay for acupuncture services (97811, 97810, 97026) provided December 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images
(D0210) provided April 27, 2021.
You asked the Plan to pay for the intraoral x-rays. You say that the x-rays should be included as part of your
dental cleaning and preventative care. The Plan denied your request. The Plan says this service is not covered
under your dental benefits.
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, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
intraoral - complete series of radiographic images (D0210) provided April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and the additional
periapical x-rays (D0230 x 2) provided on March 15, 2021.
You asked the Plan to pay for the dental services. You say that your dentist advised you needed x-rays. You
say that your front tooth needs to be fixed. You also say that your dentist is trying to prevent further tooth loss.
The Plan denied your request. The Plan says periapical x-rays are not covered benefits.
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, the periapical x-rays are not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the initial
periapical x-ray (D0220) and the additional periapical x-rays (D0230 x 2) provided on March 15, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the skilled nursing facility (SNF) care provided from September 3, 2020, through September 29, 2020. You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided. 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 $0 copayment each day, for days 1 to 20 and a $160 copayment each day, for days 21-44 for skilled nursing facility care. You have been asked to pay $960 ($160 copayment x 6 days) for the skilled nursing facility care provided. 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 copayments for the skilled nursing facility (SNF) care provided from September 3, 2020, through September 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Otezla tablets.
You asked the Plan to pre-approve Otezla tablets. You say that the enrollee has been on samples of this drug and shows improvement. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.
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 Otezla tablets.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99239) provided May 15, 2020.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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 CPT Code Manual definition of code 99239 is Hospital discharge day management, more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation does not describe the amount of time spent on this service. Based on this information, we decided that Medicare rules
for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99239) provided May 15, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services provided on September 15, 2020 by a non-participating provider.
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 were rendered by a non-participating provider without 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 had network providers available who could have provided 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 the testing services provided on September 15, 2020 by a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Urine PCR testing rendered on August 20, 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 testing is not covered.
The Plan must follow Medicare rules. The rules say that a bacterial urine culture is the standard of care for
diagnosing urinary tract infections.
We looked at the file and Medicare rules. The Urine PCR testing is not the standard of care for the enrollee's
condition and exceeds their needs. 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 Urine PCR
testing rendered on August 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide ambulance transportation to and from a physician's office. You asked the Plan to provide ambulance transportation to and from a physician's office. You say that the enrollee must be transported on a stretcher to your office. The Plan denied your request. The Plan says a physician office is a non-covered destination. Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to provide ambulance transportation to and from a physician's office. Our reviewer says that the transport by ambulance is not medically necessary. Our physician reviewer found while a wheelchair van, taxi, or car would not be an appropriate means of transportation for this enrollee, the documentation does not support that a stretcher van would be contraindicated. The documentation does not support that the enrollee in this case needs the expertise, services, and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. The documentation does not support that the ambulance transport is medically reasonable and necessary for the patient. We looked at this physician's review, the file, and Medicare rules. While a physician's office is a currently allowed destination we decided that Medicare rules for coverage of ambulance transportation to and from a physician's office have not been met. Therefore, we decided that the Plan does not have to provide ambulance transportation to and from a physician's office.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (87496, 87498, 87640, 87798) provided January 21, 2021. You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were testing purposes and are non-covered. 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 test at issue in this appeal, the genetic testing, was 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 for genetic testing (87496, 87498, 87640, 87798) provided January 21, 2021.