Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS) 
device to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve a TENS device. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested item can be provided by a network provider. 
 
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 transcutaneous electrical nerve stimulation (TENS) device to be provided by an out of network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete denture - maxillary (CPT code D5110) and complete denture - mandibular (D5120).

You asked the Plan to pre-approve the dental services. You say that you are appealing to get your dentures due to not having teeth. The Plan denied your request. The Plan says you exhausted your 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.

You exhausted your benefit because the records indicate that you were provided with complete denture -
maxillary (D5110) and complete denture - mandibular (D5140). Your 2021 EOC states that complete dentures (upper and lower) (One (1) upper complete and one lower complete denture every five (5) years, including routine post-delivery care) or Partial dentures (upper and lower) (One upper and/or one lower partial denture every five years, including routine post-delivery
care)Includes necessary extractions to fit dentures (unlimited). Therefore, we decided that the Plan does not have to pre-approve complete denture - maxillary (CPT code D5110) and complete denture - mandibular (D5120).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Intracept procedure. 
 
You asked the Plan to pre-approve Intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is experimental. 
 
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 Intracept procedure. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Intracept Procedure remains experimental for the treatment of degenerative low back pain. 
More research is needed to show safety and efficacy of the 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 Intracept procedure have not been met. Specifically, services that are considered 
experimental or investigational are not medically necessary or reasonable. Therefore, we decided that the Plan 
does not have to pre-approve Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexcom G6 Each.

You asked the Plan to pre-approve the DME. You say that the service is necessary. The Plan denied your
request. The Plan says the criteria have not been met. The Plan states they requested additional information
numerous times.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

We looked at the file and Medicare rules. There was no clinical information provided to verify if the enrollee
met the criteria for the requested service. Therefore, we decided that the Plan does not have to pre-approve
Dexcom G6 Each.
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 falls, congestive heart failure, chronic obstructive pulmonary disease (COPD) exacerbation, 
urinary tract infection. Medical problems 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. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia (01810) provided on February 11, 2020. 
 
You asked the Plan to pay for the anesthesia. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the documentation does not support the service 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. 
 
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 pay for the anesthesia. Our reviewer says that the 
documentation indicates that 37 minutes of anesthesia time were provided to this member. Our physician 
reviewer found the documentation does not support that 46 units, as minutes or blocks, were provided. 
 
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 anesthesia have not been met. Therefore, we decided that the Plan does not 
have to pay for anesthesia (01810) provided on February 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Belbuca for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under 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 Belbuca for the enrollee.

Benefits for this drug 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 continued skilled nursing facility (SNF) services.

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 continued services are not medically necessary.

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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you were admitted to the SNF after a hospitalization for a fall at home. The therapy notes state you need assistance with toileting, dressing, grooming, and bed mobility. You are able to walk 50 feet with no assistive devices. The records do not support that you have daily skilled nursing or daily skilled therapy needs. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous blood glucose monitor (CGM)(K0553) provided to the enrollee.

You asked the Plan to pay for a CGM. You say that the claim should be paid. The Plan denied your request. The Plan says The record does not contain a proof of delivery to support medical necessity for the supplies provided in this case. There is no itemized billing/shipping invoice to verify the services billed.

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 a valid proof of delivery or relevant medical records which support medical necessity for the supplies provided in this case. The documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service. 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 continuous blood glucose monitor (CGM)(K0553).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device placement surgery (22869).

You asked the Plan to pre-approve a Vertiflex Superion device placement surgery. You say that the service is
medically necessary. The Plan denied your request. The Plan says the service is experimental.

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 Vertiflex Superion device placement
surgery. Our reviewer says that the requested service is not considered medically reasonable and necessary in
this case. Our physician reviewer found the spacer device is experimental. More research is needed to show
safety and efficacy of the device.

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 Vertiflex Superion device placement surgery have not been met. Therefore,
we decided that the Plan does not have to pre-approve a Vertiflex Superion device placement surgery (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement (11042) provided by an out of network (OON) provider.

You asked the Plan to pay for the debridement. You say that you want the Plan to pay for the services. The Plan denied your request. The Plan says the services were not referred by a network provider or rendered in a participating facility. The services were not urgent or emergent and were not approved of in advance.

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 debridement (11042) provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the lab services provided on May 29, 2020. 
 
You asked the Plan to pay for the lab services. You say that lab testing is performed according to what the 
referring physician requested. The Plan denied your request.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The case file shows that the Plan dismissed the appeal for no waiver of 
liability. However, the case file includes a waiver dated within one day of the appeal letter. The Plan has not 
made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny 
your request.  Therefore, we decided that the Plan has to pay for the lab services provided on May 29, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Testopel (J3490).

You asked the Plan to pre-approve Testopel. You say that the enrollee stopped Testopel due to a shortage of pellets, and the provider could not get them until recently. The Plan denied your request. The Plan says the criteria for coverage has not been met.

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 Testopel. Our reviewer says that Testopel is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial of generic topical and injectable testosterone producst before they will approve the requested drug. Our reviewer found that the enrollee has not tried and failed the required drugs. Our physician reviewer also found that there is no documentation provided indicating that the Plan's required drugs would likely be less effective or have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Testopel have not been met. Therefore, we decided that the Plan does not have to pre-approve Testopel (J3490).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose 
monitor (CGM) and supplies for the enrollee. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the enrollee does not qualify for a CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre therapeutic continuous glucose monitor (CGM) and supplies for the enrollee.
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 a stroke. Medical problems 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. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care 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.
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 weakness and anemia. Medical problems 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. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care 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.