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

We decided that the Plan does not have to pre-approve a power seat elevation system, left side hanger, and residual limb support system for a power wheelchair (PWC).

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 covered.

The rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature.

The item at issue is a power seat elevation system. This item is not covered by Medicare for any indication.

The rules say that codes K0044 and K0047 cannot be approved with code K0861. 

The request is for a left side hanger described by procedure code K0044 or K0047. These codes cannot be approved when requested with the approved Group 3 PWC described by code K0861.

The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury.

The requested residual limb support is not needed for the enrollee. The records show that the enrollee does not have a history of amputation and therefore does not have a residual limb. The residual limb support exceeds the enrollee's needs.

Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system, left side hanger, and residual limb support system for a power wheelchair (PWC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the wheelchair accessory, power seat elevation system (E2300).
You asked the Plan to pre-approve the power seat elevation system. You say that a group 3 power wheelchair should be considered medically necessary for the enrollee. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We looked at this the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve the wheelchair accessory, power seat elevation system (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interlaminar/interspinous process stabilization/distraction device.

You asked the Plan to pre-approve insertion of an interlaminar/interspinous process stabilization/distraction device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 insertion of an interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinaous laminar distraction devices remain 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 insertion of an interlaminar/interspinous process stabilization/distraction device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interlaminar/interspinous process stabilization/distraction device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health treatment after October 25, 2021.

You asked the Plan to pre-approve the inpatient mental health treatment after October 25, 2021. You say that further inpatient mental health treatment is medically necessary. 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 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 the inpatient mental health treatment after October 25, 2021. Our reviewer says that further inpatient mental health services are not medically necessary. Our physician reviewer found the enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to herself or others and did not have any delusions or hallucinations, while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. 

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 inpatient mental health treatment after October 25, 2021 have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health treatment after October 25, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ultrasounds of the breast provided on October 9, 2020.
You asked the Plan to waive the copayments for ultrasounds of the breast. You say that you feel that the services should be considered preventative and not diagnostic. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $110 copayment for each ultrasound. You received two ultrasounds of the breast on October 9, 2020. Ultrasounds are not included in breast cancer screenings and you are responsible to pay your share of the cost-sharing charges. Therefore, you are
responsible to pay the allowed amount of $99.60 per each ultrasound. The total amount you owe is: $199.20, which is less than the total copayment amount. You have been asked to pay the total copayment amount of $199.20 for ultrasounds of the breast. Ultrasounds of the breast fall within the outpatient diagnostic tests and therapeutic services and supplies 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 copayments for ultrasounds of the breast provided on October 9, 2020.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve home health aide visits (G0156).

You asked the Plan to pre-approve home health services. You say that the aide services are medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 home health services. Our reviewer says that home health aide services are medically necessary. Our physician reviewer found the enrollee currently has documented skilled nursing needs (i.e. PEG site observation, wound care). The enrollee is noted to be bedfast and incontinent. Assistance in bathing and dressing the patient, so as to keep her skin clean and dry is medically necessary and reasonable to assist in her wound healing. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have been met. Therefore, we decided that the Plan has to pre-approve home health aide visits (G0156).

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 a recliner chair.

You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered under Medicare or the health plan.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a recliner chair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas NeoGen therapy with Nutri-Pharmaceutical injections (G0283, 96372, 97150, J3490, J3411, J3415, J7999 and 97139) provided on March 16, 2021.

You asked the Plan to pay for the Sanexas NeoGen therapy with Nutri-Pharmaceutical injections. You say that you would like reconsideration because this service was medically necessary The Plan denied your request. The Plan says screening testing is not a Medicare covered benefit.

The Plan must follow Medicare rules. Medicare rules say that claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code. The rules also say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Sanexas NeoGen therapy with Nutri-Pharmaceutical injections have not been met. Specifically, after review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Oklahoma. 

Additionally, the multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. CPT code J7999 does not meet criteria for billing or reimbursement consideration because the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Therefore, we decided that the Plan does not have to pay for the Sanexas NeoGen therapy with Nutri-Pharmaceutical injections (G0283, 96372, 97150, J3490, J3411, J3415, J7999 and 97139) provided on March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extraction, erupted tooth requiring removal of bone
and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) performed by an
oral surgeon.
You asked the Plan to pre-approve a tooth extraction. You say that no one told you that you need a referral for
the service. The Plan denied your request. The Plan says you do not have a referral to see an oral surgeon.
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 two tooth
extractions per year when performed by a participating general dentist.
We looked at the file and Medicare rules. In this case the service is requested to be performed by an oral
surgeon. Based on this information, we decided that the Plan's rules for coverage of a tooth extraction have not
been met. Therefore, we decided that the Plan does not have to pre-approve an extraction, erupted tooth
requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated
(D7210) performed by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ankle brace (L1940, L2820, L2330) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an ankle brace. You say that you are comfortable with this provider. 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 an ankle brace (L1940, L2820, L2330) to be provided by an out-of-network (OON) provider
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 continued services. You say that your condition has not improved. The Plan denied your request. The Plan says daily skilled services are not needed.

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.

Continued SNF services beyond October 25, 2021, were requested. 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 continued services. Our physician reviewer found that you were not expected to make measurable gains within a reasonable period of time. You do not require skilled therapy to prevent deterioration with mobility or activities of daily living. You do not have any parental medications, complex wound care or nutrition given via a feeding tube. Your function is at or near your prior level of function. You do not require any skilled services on a daily inpatient basis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued 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: 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.

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 there is no indication that you would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain your functional status. You require skilled rehab services, but these services can be provided 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the therapeutic, prophylactic, or diagnostic injection (96374),
technetium tc-99m sestamibi (A9500) and the regadenoson injection (J2785) provided on February 9, 2021.

You asked the Plan to pay for the injection, technetium tc-99m sestamibi and regadenoson. You say that you
would like reconsideration because these services should be paid. The Plan denied your request. The Plan has
not addressed the services being appealed.

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.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, the Plan has failed to address the services at issue. 

The Plan has not
submitted and evidence as to why the services at issue have been denied. It is the burden of the Health Plan to
substantiate the denial with evidence. This denial has not been substantiated so we must find in your favor.
Therefore, we decided that the Plan has to pay for the therapeutic, prophylactic, or diagnostic injection (96374),
technetium tc-99m sestamibi (A9500) and the regadenoson injection (J2785) provided on February 9, 2021.

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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sclerotherapy treatment.
You asked the Plan to pre-approve sclerotherapy treatment. You say that the services 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 sclerotherapy treatment is covered under certain circumstances. 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 sclerotherapy treatment. Our reviewer says that the services are not medically necessary. Our physician reviewer found the criteria states that invasive procedures are medically necessary when a duplex scan confirms the presence of venous reflux greater than 500 ms and absence of deep venous obstruction. The review has determined that the enrollee does not meet the coverage criteria detailed in the LCD. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sclerotherapy treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve sclerotherapy treatment.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.
You asked the Plan to pre-approve the skilled nursing facility services. You say that the services are medically necessary. 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 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 skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet and tending to activities of daily living with minimal supervision. 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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laboratory services to be provided by an out-of-network (OON) provider.
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 available from 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 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 laboratory services to be provided by an out-of-network (OON) provider