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

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that your condition is one where you cannot be released from the hospital with a medical facility to assist your quality of life. The Plan denied your request. The Plan says your records do not show you do not require skilled nursing services or skilled rehabilitation services on a daily basis, and which can only be provided on an inpatient basis in a SNF. The Plan states your rehabilitation and medical needs can be met with part-time skilled services in a lower level of care, such as home with supervision and home health services. The Plan states home health services will need to be approved by your health plan. The Plan states your rehabilitation needs can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with your doctor.
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 do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are functioning near your baseline. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6750 x 4) for teeth # 22, 24, 25, and 26, and a pontic (D6240) for tooth # 23.

You asked the Plan to pre-approve the dental services. You say that teeth # 24, 25 and 26 were damaged during a procedure for your upper teeth provided by a different dental office. You say that these teeth are close to completely fracturing at the gum. You say that your dentist advised that you need an anterior lower bridge as single crowns cannot repair the damage done. The Plan denied your request. The Plan says the requested bridge is 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. The Plan covers the dental services when the services are medically necessary and reasonable. 

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 dental services. Our reviewer says that the requested fixed bridge does not meet the criteria for coverage. Our physician reviewer found the requested bridge is beyond the scope of the plan. The provided documentation indicates that one mandibular anterior tooth is being replaced (# 23) and multiple bilateral posterior teeth are missing. The reviewer also found that it cannot be determined by the radiographs provided if there is significant coronal breakdown of teeth # 22, 24, 25 and 26 to warrant crown restorations. Therefore, the reviewer found that the requested bridge does not meet the criteria for coverage.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the file shows that the bridge is needed to replace a posterior tooth. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6750 x 4) for teeth # 22, 24, 25, and 26, and a pontic (D6240) for tooth # 23.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an at home sleep study test (G0399)
provided on July 6, 2021.
You asked the Plan to waive the copayment for at home sleep study test. You say that the services should be
covered as you felt there was no option on whether or not to take the home test. The Plan denied your request.
The Plan says the cost sharing applied correctly based on the services 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 $150
copayment for Outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a $150 copayment for an at home sleep study test. Sleep study tests 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 copayment for an at home sleep study test (G0399) provided on July 6, 2021.
Your complaint about potentially being misled 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
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 criteria for coverage are not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses
adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that you do not treat with insulin three
or more times per day. The file shows you use insulin once per day. 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 continuous glucose monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation (A0100).
You asked the Plan to pre-approve additional routine transportation. You say that you need additional transportation. You say that you have mobility problems. You also say that you do not have family that can help you. The Plan denied your request. The Plan says you have used 16 one-way trips so far in 2021. The Plan says that you have 8 one-way trips remaining for the year. The Plan also says that any trips in excess of the allowed 24 one-way trips are not covered.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year. We looked at your request, the records in the case file, and the rules. The record shows that you have not exhausted the Plan maximum benefit for coverage of routine transportation for 2021. However, additional trips beyond the 24 one-way trips are not covered. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation (A0100).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
You asked the Plan to pre-approve the additional non-emergency transportation. You say that you are alone,
have some therapies pending, your hands are bad, and you need the transportation. The Plan denied your
request. The Plan says as of November 18, 2021 you have used 45 one-way trips this year and have 7 one-way
trips available.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of fifty-two (52) one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you will or have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 2 System.
You asked the Plan to pre-approve a Freestyle Libre 2 System. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 2 System have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 System.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271).
You asked the Plan to pre-approve Keytruda. You say that this is medically necessary. The Plan denied your
request. The Plan says Keytruda is not approved by the Food and Drug Administratio (FDA) for the enrollee's
diagnosis. The Plan also says that the enrollee's MicroSatellite Instability (MSI)/deficient MisMatch Repair
(dMMR) status is unknown, therefore it is unknown if this therapy will be effective.
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 Keytruda. Our reviewer says that
Keytruda is not medically necessary. Our physician reviewer found the provided records do not document the
MicroSatellite Instability-high (MSI-H) or MisMatch Repair deficient (dMMR) status of this enrollee's tumor.
The reviewer found that there is no documentation that the use is supported by one of the major drug
compendia or by clinical research that appears in a CMS-approved medical journal.
Therefore, the requested use of Keytruda is not Food and Drug Administration-approved for the enrollee's diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Specifically, the file does not support that the requested drug is FDA-approved for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9271).
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 enrollee can safely receive the needed care in another setting.

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 is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids from an out-of-network provider.
You asked the Plan to pre-approve the hearing aids. You say that your hearing is compromised, and you
desperately need new hearing aids. You say that the network hearing aids are double the cost and you cannot
afford them. The Plan denied your request. The Plan says this provider is not a Plan designated hearing vendor.
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. The Plan pays for
hearing aids only when they are received from the Plan's hearing aid vendor.
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-
approve hearing aids from an out-of-network provider.
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 this is medically necessary. The Plan denied your
request. The Plan says the complexity of the enrollee's needs do not require an acute inpatient hospital stay.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for gangrene and osteomyelitis with amputation of 4th and 5th toe and lower extremity
revascularization surgery. Medical problems are stable. There are no complex nursing or rehabilitation needs.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically
necessary care can be provided in a different level of care. There is not a reasonable expectation that this
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program
provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to provide additional payment for inpatient hospital services provided on July 19, 2020, through August 6, 2020.

You asked the Plan to provide additional payment for the inpatient hospital services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the documentation does not support a diagnosis of malnutrition.

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 not forwarded sufficient information to determine what services are at issue and why. There is no indication of what diagnosis code is not supported or why the Diagnosis Related Group has been adjusted. Of note, the Plan indicates that the records do not support a diagnosis of malnutrition, but the claim was not billed with this diagnosis. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to provide additional payment for inpatient hospital services provided on July 19, 2020, through August 6, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0652) and segmental
pneumatic appliance (E0667).
You asked the Plan to pay for a pneumatic compression device. You say that please see attached
documentation from the enrollee's healthcare team in support of medical necessity of the prescribed Flexitouch
PCD for the treatment of lymphedema. The Plan denied your request. The Plan says the enrollee does not meet
the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic
compression device of either E0650 or E0651 and the records show you have swelling only in your legs.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance
provided. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device
(E0652) and segmental pneumatic appliance (E0667).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of ruptured breast implant (19330) and revision of a reconstructed breast (19380) provided on March 25, 2019.

You asked the Plan to pay for the removal of a ruptured breast implant and revision of a reconstructed breast. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We asked our coder 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 removal of a ruptured breast implant and revision of a reconstructed breast. Our reviewer says that CPT codes 19380 and 19330 do not meet criteria for billing or reimbursement consideration.

The medical records provided do not include sufficient documentation to validate a revision of reconstructed breast (eg, significant removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction) being performed on March 25, 2019, therefore this procedure cannot be verified. Our reviewer found the medical records provided document the removal of ruptured breast implant, including implant contents (eg, saline, silicone gel) being performed on March 25, 2019, however, 19330 51 RT is considered inclusive to CPT 19342 50 - delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction, therefore 19330 51 RT is not eligible for separate reimbursement consideration. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the removal of a ruptured breast implant and revision of a reconstructed breast have not been met. Therefore, we decided that the Plan does not have to pay for the removal of ruptured breast implant (19330) and revision of a reconstructed breast (19380) provided on March 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue
regeneration (D3431).

You asked the Plan to pre-approve the biologic materials. You say that you need a root canal and tissue
regeneration in order to have the crown put in. The Plan denied your request. The Plan says this service is not
covered under your benefit plan.

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 pre-approve
biologic materials to aid in soft and osseous tissue regeneration (D3431).