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

We decided that the Plan does not have to pre-approve continued skilled nursing facility services.

You asked the Plan to pre-approve continued skilled nursing facility services. You say that continued coverage 
for the skilled nursing facility services is medically necessary. The Plan denied your request. The Plan says 
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 continued skilled nursing facility 
services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based 
on the medical records provided, daily skilled services are not required. Skilled nursing facility services beyond 
the last covered date of January 30, 2022, are 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 continued skilled nursing facility services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued skilled nursing facility services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections (J0585).

You asked the Plan to pre-approve Botox injections. You say that Botox is medically necessary. The Plan denied your request. The Plan says a trial of Xeomin is required before alternatives can be considered.

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 Botox injections. Our reviewer says that Botox is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drug or any reason it would be unsafe or ineffective for this 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 Botox injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox injections (J0585).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit (99335) provided July 21, 2021.

You asked the Plan to pay for a domiciliary or rest home visit. You say that you would like reconsideration based on the medical records provided. The Plan denied your request. The Plan says services were provided out of network without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit (99335) provided July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (97012) provided on June 18, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services (97012) provided on June 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rybrevant (J9061).
You asked the Plan to pre-approve Rybrevant. You say that Rybrevant is medically necessary. The Plan denied
your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Rybrevant. Our reviewer says that
Rybrevant is not medically necessary. Our physician reviewer found the use of Rybrevant in this setting is not
supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical
journal.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Rybrevant have not been met. Therefore, we decided that the Plan does not
have to pre-approve Rybrevant (J9061).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided from April 15, 2021, to April 21, 2021.
You asked the Plan to pay for the inpatient services. The Plan denied your request. The Plan says DRG 219 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 219. 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 inpatient services. Our reviewer says that the use of DRG 219 is not supported by the records provided. Our physician reviewer found that the enrollee presented for an elective admission for Aortic valve replacement and Coronary artery bypass graft surgery (CABG). Per the discharge summary the procedure was uncomplicated and does not state for pulmonaryhypertension. This is only noted in the immediate post-op period, and the enrollee was in the ICU after, without vasopressors. The extubation time was not documented here, however there is no ventilator coded for greater than 24 hours. The review has determined that the billing of DRG 219 is not supported by the records provided. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient services provided from April 15, 2021, to April 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on May 5, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are
not payable.
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate.
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for
the lab services provided on May 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the magnetic resonance imaging (MRI) of
the lumbar spine without contrast (72148) provided on September 7, 2021.

You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a
physician's office or at a free standing facility (such as a radiology center or medical clinic).

You have been asked to pay a $110 copayment for the Medicare-covered radiological diagnostic service
provided. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to adjust the copayment for the magnetic resonance imaging (MRI) of the
lumbar spine without contrast (72148) provided on September 7, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular pathology procedure (81479), provided on July
10, 2021.
You asked the Plan to pay for the molecular pathology procedure. You say that the service should be covered.
The Plan denied your request. The Plan says the fee-for-service (FFS) benefit is the time where the member
revokes hospice till the start of the new month. During this time Traditional or Original Medicare is still
responsible for payment of medical services both unrelated and related to the hospice diagnosis.
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 molecular pathology procedure (81479), provided on July
10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lead wires (A4595), provided on September 23, 2021.
You asked the Plan to pay for the lead wires. You say that the item should be covered. The Plan denied your
request. The Plan says since a TENS unit has been purchased in the previous 12 months, it would not be
appropriate to bill for lead wires separately within the 12 months after purchase.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The file shows that the member was approved for a TENS unit within the past twelve months which includes
lead wires. The lead wires included in the approved TENS device serves the same purpose as the lead wires
requested. Replacement of these lead wires within twelve months is not medically necessary or reasonable.
Therefore, we decided that the Plan does not have to pay for the lead wires (A4595), provided on September
23, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services (A0425), provided on June 17, 2021.
You asked the Plan to pay for the ambulance service. You say that the service should be covered. The Plan
denied your request. The Plan says The Medicare hospice benefit, through fee- for-service Medicare, covers all
hospice care from the effective date of election to the date of discharge or revocation.
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 ambulance services (A0425), provided on June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the partial upper denture (D5213) provided on September 9, 2021.  You asked the Plan to pay for the partial denture. You say that you feel that the plan should cover a broken tooth and all repairs and extraction. You say that you feel that the plan is responsible for your tooth replacement. You also say that at least some of this should be covered. The Plan denied your request. The Plan says partial upper denture is not listed as a covered service.  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 partial upper denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the partial upper denture (D5213) provided on September 9, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee's needs SNF services to regain her
strength. The Plan denied your request. The Plan says that the enrollee does not require complex daily nursing
care that must be provided in a skilled nursing facility.
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 necessary. Our physician reviewer found that the enrollee's condition does not
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an oral device (E0486) received May 6, 2021.

You asked the Plan to pay for an oral device. You say that this is an unfair financial burden to you as you thought you'd at least get partial coverage. The Plan denied your request. The Plan says this provider is an opt out provider and these services are therefore not eligible for reimbursement.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an oral device (E0486) received May 6, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from
February 2, 2021, through March 5, 2021.
You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says
continuation of SNF services was 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 pay for continuation of SNF services. Our reviewer
says that daily skilled services are not medically necessary. Our physician reviewer found based on the medical
records provided there is no documentation that the enrollee required skilled nursing services, i.e., the
specialized skill, knowledge and judgment of a skilled professional nurse were not required to safely and
effectively provide medically necessary and reasonable treatment. This enrollee did not require skilled therapy
services, i.e., the specialized skill, knowledge and judgment of a qualified therapist were not required to safely
and effectively provide medically necessary and reasonable treatment. Daily skilled services were not required.
As a practical matter, this enrollee did not require the services on an inpatient basis, only in a skilled nursing
facility setting. Services in the nursing facility appear custodial in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the
Plan does not have to pay for continuation of SNF services provided from February 2, 2021, through
March 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion or replacement of breast implants (19342)
and revision of reconstructed breast (19380).
You asked the Plan to pre-approve the insertion or replacement of breast implants (19342) and revision of
reconstructed breast (19380). You say that you have experienced a tremendous amount of pressure, heaviness,
discomfort, tenderness and fluid buildup in both of your breasts ever since surgery. You say that the doctor
advised a revision would be beneficial to alleviate the issues and are requesting reconsideration for this
procedure to be approved. The Plan denied your request. The Plan says the clinical documentation does not
note a high grade of capsular contracture or other medically necessary findings that are not cosmetic.
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 the insertion or replacement of breast
implants (19342) and revision of reconstructed breast (19380). Our reviewer says that the documentation does
not support that the coverage criteria established have been met. Our physician reviewer found that the
documentation does not support that the enrollee has a mechanical complication of the breast prosthesis,
infected breast implant or rejection of breast implants, other complications of internal breast implant, and /or
painful capsular contracture with disfigurement.
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 insertion or replacement of breast implants (19342) and revision of
reconstructed breast (19380) have not been met. Therefore, we decided that the Plan does not have to pre-
approve the insertion or replacement of breast implants (19342) and revision of reconstructed breast (19380).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the stem cell transplantation you received from April 26,
2021, to May 26, 2021.
You asked the Plan to pay for the stem cell transplant. The Plan denied your request. The Plan says this is not
medically necessary.
The Plan follows Medicare rules. Medicare rules say that stem cell treatment is covered for the indications
established in the applicable NCD.
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 stem cell transplant. Our reviewer says
that the requested stem cell treatment was not medically reasonable and necessary. Our physician reviewer
found that neuropathy with back pain and leg pains is not a covered diagnosis for stem cell treatment as
detailed in the NCD.
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 stem cell transplant have not been met. Therefore, we decided that the Plan
does not have to pay for the stem cell transplantation you received from April 26, 2021, to May 26, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the interpretation of a home sleep test 
(G0399), provided on February 22, 2021.

You asked the Plan to waive the copayment for the interpretation of a home sleep test. You say that the service 
should be covered. The Plan denied your request. The Plan says the cost share was 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 a $150 
copay for outpatient hospital services.

You have been asked to pay a $150 copay for the interpretation of a home sleep test. This service falls within 
the outpatient hospital services 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 copayment for
the interpretation of a home sleep test (G0399), provided on February 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for air ambulance services provided on June 22, 2020.
You asked the Plan to pay for air ambulance services provided on June 22, 2020. The Plan denied your request.
The Plan says air ambulance transportation is not medically necessary for the circumstances in this case.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your
medical condition is such that transportation by ground ambulance is not appropriate.
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 air ambulance services provided on
June 22, 2020. Our reviewer says that the air ambulance services did not meet the Medicare coverage criteria.
Our physician reviewer found that the documentation did support that you suffered from an illness or injury
that contraindicates transportation by any means other than ambulance. The documentation did not support that
your condition was such that the time needed to transport by ground, or the instability of transportation by
ground, posed a threat to your survival or seriously endangered your health. The documentation did not support
that the transferring hospital did not have adequate facilities to provide the medical services needed by you.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of air ambulance services provided on June 22, 2020 have not been met.
Therefore, we decided that the Plan does not have to pay for air ambulance services provided on June 22, 2020.