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

We decided that the Plan does not have to pre-approve SNF services.

You asked the Plan to pre-approve SNF services. You say that SNF care is medically necessary. The Plan denied your request. The Plan says per Medicare guidelines, the enrollee exceeds mobility and activities of daily living criteria.

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 services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found the enrollee has stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehabilitation services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. She is medically stable without any acute exacerbations of chronic medical problems. Her physical function is at or near her baseline and she can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services is not medically necessary. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5258) provided on January 20, 2021.
You asked the Plan to pay for hearing aids. You say that the items at issue are medically necessary and they should be covered. The Plan denied your request. The Plan says the items were received from a non-participating provider and are not covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Specifically, the items were received from an out-of-network vendor and are not covered. Therefore, we decided that the Plan does not have to pay for hearing aids (V5258) provided on January 20, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled therapy 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 services are not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 records do not support that the enrollee requires skilled rehab services to provide treatment that is medically necessary. She does not require additional skilled rehab services to effectively provide treatment, care, and/or services in order to improve his condition, perform a maintenance program, or maintain her condition or prevent further deterioration. She has been medically stable without recent exacerbations of chronic medical problems or hospitalizations. She has previously received physical therapy and her caregiver has been educated regarding a home exercise program. The requested home health physical therapy is not medically necessary. 

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 home health skilled therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dentures (D5110).

You asked the Plan to pre-approve the dentures. You say that this is medically necessary. The Plan denied your request. The Plan says coverage for dentures is limited to once every five years.

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 dentures once every five years. 

Dentures were last received less than five years ago on 2/14/18. Based on this information, we decided that the Plan's rules for coverage of the dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve dentures (D5110).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.

You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device is not medically necessary.

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 device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy. The requested Vertiflex device is not medically necessary 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown (D2740) provided on February 12, 2021.

You asked the Plan to pay for a crown. You say that you were not aware that the provider was out-of-network and you were told you would receive a discount on the service. The Plan denied your request. The Plan says the service at issue is not a covered 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. 

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 a crown (D2740) provided on February 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
You asked the Plan to pre-approve the mandibular partial denture. You say that you have the original dentures, but they do not fit. You also say that the proper adjustments were not made to your dentures, and they are still not tight. The Plan denied your request. The Plan says this service is only covered 1 time in a 60-month time period. The Plan also says that you have already had this service done in that time period.
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, you are limited to 1 complete or partial denture every 5 years. The record shows that you received a mandibular partial denture (D5214) on June 8, 2020 and your mandibular denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse weight management allowance for the 2020 benefit year.

You asked the Plan to reimburse weight management allowance. You say that you submitted the weight management reimbursement request for $150 and it was denied because the request was received 04/01/2021 and you feel that the reimbursement should be processed. The Plan denied your request. The Plan says only proof of payment for $39.90 was received for weight management services in 2020.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits when submitted with a wellness allowance reimbursement form along with proof of payment and any additional information outlined on the form.

The Plan's rules for coverage of gym benefits have not been met because the proof of payment received only showed payment for $39.90 for weight management services in 2020. Therefore, only reimbursement of $39.90 is covered and the remaining amount of $110 is denied. The weight management allowance falls within the Health and wellness education programs 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 reimburse weight management allowance for the 2020 benefit year.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on March 26, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. 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 the services provided by an out-of-network provider on March 26, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide acute inpatient hospital care after surgery.
You asked the Plan to provide acute inpatient hospital care after knee arthroscopy. You say that you live alone and do not have support after your surgery. The Plan denied your request. The Plan says the approved total knee replacement is not on the Medicare inpatient only list.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care after knee arthroscopy. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record indicates that the enrollee is scheduled for a total
knee arthroplasty. The record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights. The enrollee may be admitted for observation. The elements of the coverage rule are not satisfied. The requested service is not recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care after knee arthroscopy have not been met. Therefore, we decided that the Plan does not have to provide acute inpatient hospital care after surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation provided on May 14, 2021.
You asked the Plan to pay for the limited oral evaluation. You say that you would rather the Plan pay for the irrigation to keep things clean as opposed to paying for surgery. You say that the service should be reconsidered as a preventive measure. The Plan denied your request. The Plan says services from out-of-network providers are not covered.
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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation provided on May 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics (L3221) provided on March 17, 2021.

You asked the Plan to pay for foot orthotics. You say that the requested item is a necessity for your care. The Plan denied your request. The Plan says the requested item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics (L3221) provided on March 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based filling (D2391) provided on March 29, 2021.

You asked the Plan to pay for the dental filling. You say that these services should be covered by your dental benefit. The Plan denied your request. The Plan says they have agreed to cover the preventative dental services; however, fillings and restorations are not covered by your dental 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.

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 resin-based filling (D2391) provided on March 29, 2021.
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 you are at risk for further decline and complications of immobility without continued rehabilitation services The Plan denied your request. The Plan says the documentation received does not indicate that there are comorbidities that would require close supervision by a rehabilitation physician; nor is there documentation that there is a need for a required intensive and coordinated interdisciplinary approach to providing rehabilitation.
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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you 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.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of doxorubicin liposome and ondansetron.
You asked the Plan to pre-approve doxorubicin liposome and ondansetron. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for these drugs is correct, because the Plan requires a trial of anthracycline-based therapy (such as conventional doxorubicin or epirubicin therapy) before it will approve doxorubicin liposome and ondansetron.
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 doxorubicin liposome and ondansetron. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for these drugs. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drugs of conventional doxorubicin or epirubicin. The documentation does not support that these drugs would likely be less effective and/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 doxorubicin liposome and ondansetron have not been met. Therefore, we decided that the Plan does not have to pre-approve use of doxorubicin liposome and ondansetron.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve facet joint injections. You say that the requested facet joint injections are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested facet joint injections.
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 facet joint injections. Our reviewer says that the enrollee does not meet criteria for the requested facet joint injections. Our physician reviewer found repeated intra-articular facet joint injections as a series is not supported by the peer-reviewed literature. The request does not meet the LCD criteria and therefore, the request is deemed not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have the pay for the acupuncture services provided on March 4, 2021.
You asked the Plan the pay for the services. The Plan denied your request. The Plan says this is not a covered
benefit.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20
sessions per year. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the records do not show that the acupuncture services were provided for the treatment of CLBP. Therefore, we decided that the Plan does not have the pay for the acupuncture services provided on March 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you are not able to walk or care for yourself. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services you and/or your provider are requesting do not meet the requirements for approval.

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 that based on the documentation provided, the health Plan's denial should be upheld. You do not require the intensity of services provided at an IRF.

Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care (ex. skilled nursing facility/subacute rehabilitation). 

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 IRF admission and services.