Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the vitamin injections provided on March 29, 2021.

You asked the Plan to pay for the vitamin injections. You say that you submitted the medical records to show
the medical necessity. You say that the claim should be reviewed and reprocessed for correct payment. The
Plan denied your request. The Plan says the codes on the claim are denied.

The Plan must follow Medicare rules. The rules say that beginning in July 2015, claims for compounded drugs
shall be submitted using a compounded drug, not otherwise classified (NOC) code.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the vitamin injections have not been met. Specifically, 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. Therefore, we decided that the Plan does not have to pay for the vitamin injections
provided on March 29, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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 must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has made slow progress with therapy, there is no indication that transfer to a skilled nursing facility is required. He can continue to receive skilled rehabilitation services at the current inpatient rehabilitation facility (IRF) or be stepped down to a lower level of care when appropriate. There are no services offered at a SNF that are not offered at an IRF. Admission to a SNF for inpatient skilled rehab 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says the rules for SNF care have not been met as your needs are custodial in nature.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are an 81-year-old female with a right hip fracture. In this case, while there are identifiable skilled therapy service needs there are no identifiable skilled nursing needs. In addition, you do not require skilled nursing or therapy services on a daily basis. In conclusion, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep brain stimulator implantation.

You asked the Plan to pre-approve deep brain stimulator implantation. 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 for subthalamic nucleus (STN) or globus pallidus interna (GPi) deep brain stimulation (DBS) to be considered reasonable and necessary, patients must meet specific criteria. 

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 deep brain stimulator implantation. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee would need to meet all the coverage criteria in the NCD to qualify for coverage. The documentation in the case file does not support that the enrollee has advanced idiopathic Parkinson's disease, as determined by the use of Hoehn and Yahr stage or Unified Parkinson's Disease Rating Scale (UPDRS) part III motor subscale. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of deep brain stimulator implantation have not been met. Therefore, we decided that the Plan does not have to pre-approve deep brain stimulator implantation.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management provided on April 21, 2020.

You asked the Plan to pay for the hospital discharge day management. The Plan denied your request. The Plan says Original Medicare is responsible for payment.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management provided on April 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular genetic testing provided on
January 19, 2021.
You asked the Plan to pay for the services provided. You say that the services are covered by Medicare. The
Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels
for suspected or documented cardiovascular disease.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
We looked at the file and the rules. The limited records show that the enrollee has no personal history of
cardiac conditions. The test at issue in this appeal 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
the hereditary cardiovascular genetic testing provided on January 19, 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 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 the enrollee does not require physical medicine & rehabilitation (PM&R) physician
supervision 3 times per week for the ongoing management of any active or acute exacerbations of chronic
medical conditions. The enrollee has no documented rehab nursing needs. CMS guidelines require that the
enrollee make significant progress in a reasonable and predicted period. The enrollee will not be able to meet
this expectation based on a physical therapist's (PT) note. The enrollee does not require an intensive, complex,
multidisciplinary approach to daily therapy in an IRF. Documentation does not support the need for therapy
program consisting of at least 3 hours of therapy per day at least 5 days per week with frequent physician
oversight and an interdisciplinary approach to rehabilitation 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: Unfavorable

We decided that the Plan does not have to pre-approve the Testopel.
You asked the Plan to pre-approve the Testopel. You say that the service is medically necessary. The Plan denied your request. The Plan says the records did not contain results of the required tests.
The Plan follows Medicare rules. Medicare rules say that requirements for diagnosing low testosterone are two separate serum testosterone levels taken on two different days in the morning (when testosterone secretion is highest), and / or two morning levels of "free" or bioavailable testosterone) and two other hormones as well, luteinizing hormone (LH) or follicle stimulating hormone (FSH). 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 Testopel. Our reviewer says that the service is not medically necessary. Our physician reviewer found the records did not contain results of the required tests. 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 Testopel have not been met. Therefore, we decided that the Plan does not have to pre-approve the Testopel.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis services provided from April 6,
2021, through April 27, 2021.
You asked the Plan to waive the coinsurance for dialysis services. You say that you need these treatments to
stay alive, but you cannot pay the copayments. The Plan denied your request. The Plan says the coinsurance
applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Medicare-covered dialysis services within the service area when ordered by your PCP.
You have been asked to pay $65.52, which is 20% of the allowed amount for each visit for dialysis services.
The allowed amount is $327.60 (20% x $327.60 = $65.52). The total amount you owe is $458.64 ($65.52/visit
x 7 visits = $458.64). Dialysis services falls within the "Services to treat kidney disease" 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 coinsurance for dialysis services provided from April 6, 2021, through
April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and bitewing x-rays (D0274) provided on April 27, 2021.
You asked the Plan to pay for the dental services. You say that this visit was for a second opinion. You say that the initial dentist made recommendations that your primary care provider did not agree with. You say that you needed this second opinion for surgery clearance. The Plan says 1 comprehensive or periodontal exam is covered every 3 years. The Plan says that 1 set of bitewing x-rays is covered per calendar year. The Plan also says that the frequency limits for these services have been exceeded.
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 and the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation and bitewing x-rays that you received on April 22, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and bitewing x-rays (D0274) provided on April 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a stairway elevator provided on February 1, 2021.
You asked the Plan to pay for a stairway elevator. You say that you were informed by a representative of the Plan that the Plan would pay 80% of the cost of the item at issue. The Plan denied your request. The Plan says the item at issue is not a Medicare or Plan 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 pay for a stairway elevator provided on February 1, 2021.
Your complaint about receiving erroneous or incomplete information about your benefits from a representative
of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to LTACH.
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. The enrollee was admitted with a pyothorax and underwent surgical procedures. The enrollee also had acute respiratory failure secondary to necrotizing pneumonia. The enrollee continues to receive acute care services and these
have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a supply allowance for a continuous glucose monitor (K0553) provided on March 18, 2021.

You asked the Plan to waive the coinsurance for a supply allowance for a continuous glucose monitor. The Plan denied your request. The Plan says the correct coinsurance was applied.

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 20% coinsurance for durable medical equipment. 

You have been asked to pay $93.50, or 20% of the Medicare-allowed charge of $467.49, for a supply allowance for a continuous glucose monitor. A supply allowance for a continuous glucose monitor falls within the "Durable medical equipment (DME) and related 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 coinsurance for a supply allowance for a continuous glucose monitor (K0553) provided on March 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation device, vasopneumatic device and multivitamin injection provided on February 2, 2021.

You asked the Plan to pay for the transcutaneous electrical nerve stimulation (TENS) device, vasopneumatic device and multivitamin injection represented by codes 97032, 97139, J3490 and J7999. You say that the enrollee has suffered from chronic pain in the feet and tried other modalities. The Plan denied your request. The Plan says the TENS device is not supported, vitamin injections are not covered, and vasopneumatic devices are only for the treatment of chronic venous insufficiency with venous stasis ulcers and refractory lymphedema.

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 vasopneumatic device is to reduce edema or lymphedema, treatment of chronic foot pain with this device is not considered medically reasonable and necessary. Vitamin injections into the nerve and musculoskeletal structures are not a Medicare covered service. There is no documentation of chronic foot pain for over 3 months or of other modalities tried, therefore criteria of the TENS device is not met. Based on this information, we decided that Medicare rules for coverage of the transcutaneous electrical nerve stimulation device, vasopneumatic device and multivitamin injection represented by codes 97032, 97139, J3490 and J7999 have not been met. Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation device, vasopneumatic device and multivitamin injection provided on February 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a set of repeat medial branch block injections (MBBs).

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. Medicare rules say that repeat facet injections are covered when specific criteria are met. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. He had spine surgery with a bone stimulator in place. He had bilateral MBBs with 75 percent pain relief. The criteria for coverage of repeat injections are not met and the services are therefore not reasonable or 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 a set of repeat medial branch block injections (MBBs).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Onetouch Verio test strips.

You asked the Plan to pre-approve the Onetouch Verio test strips. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical Equipment (DME) to only those preferred brands and manufacturers.

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 Onetouch Verio test strips. Our reviewer says that the service is not medically necessary. Our physician reviewer found the record does not indicate the medical reason why the requested item is needed instead of one of the plan's available preferred brands. 

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 Onetouch Verio test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve the Onetouch Verio test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple power options.

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. Medicare rules say that a Group 3 PWC is covered when specific criteria are met. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the criteria for coverage are not met. Our physician reviewer found the enrollee has a history of diabetes, hypertension, dermatomyositis and neuropathy with paraplegia. She has a personal mobility deficit that impairs participation in mobility related activities of daily living (MRADLs) in the home that cannot be helped by the use of a cane, walker, or manual wheelchair. The records do not support that the enrollee meets all of the criteria for coverage of the Group 3 PWC with multiple power options or need for a power tilt. The services are therefore not reasonable or 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 a Group 3 power wheelchair (PWC) with multiple power options.