Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the six office consultations and treatment to be provided by an OON provider.  You asked the Plan to pay for the six office consultations and treatment. You say that the enrollee has been treated by this doctor since February 2021. You say for better continuity of care, it would be best that she can follow-up with the out-of-network provider to continue management of her left knee pain. The Plan denied your request. The Plan says the provider is out-of-network.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 the six office consultations and treatment to be provided by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya (J3245).

You asked the Plan to pre-approve Ilumya. You say that the enrollee has tried and failed several topical 
steroids. You say that you do not feel comfortable writing systematic or oral medications. You also say that 
you feel this is the best next step in the enrollee's treatment. The Plan denied your request. The Plan says the 
enrollee has not tried and failed at least 2 of the preferred drugs, Humira, Rinvoq, Skyrizi, Actemra 
(subcutaneous), Cosentyx, Otezla, Xeljanz or Xeljanz XR, Orencia (subcutaneous), and Enbrel.

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 Ilumya. Our reviewer says that Ilumya 
is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the 
enrollee has tried and failed at least 2 of the preferred drugs. The reviewer also found that the provided 
documentation is insufficient to support that any of the preferred drugs, Humira, Rinvoq, Skyrizi, Actemra 
(subcutaneous), Cosentyx, Otezla, Xeljanz or Xeljanz XR, Orencia (subcutaneous), and Enbrel would likely be 
less effective, and/or would likely have adverse effects for the enrollee 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 Ilumya have not been met. Specifically, the file does not indicate that the 
enrollee has tried and failed at least 2 of the preferred drugs. Therefore, we decided that the Plan does not have 
to pre-approve Ilumya (J3245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve unlisted procedure, dentoalveolar structures (41899).
You asked the Plan to pre-approve the dental service. You say that the enrollee has been on medication that has
many side effects, including bone loss. You say that your remaining teeth are fragile making it difficult for you
to eat. You say that the enrollee needs these services as soon as possible. The Plan denied your request. The
Plan says the requested services are routine dental in nature. The Plan also says that routine dental services are
not covered.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve unlisted procedure,
dentoalveolar structures (41899).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee.
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan
denied your request. The Plan says that the request for a home mechanical ventilator set in AVAPS mode that
could be delivered by BiPAP is not covered.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.
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 portable ventilator. Our reviewer says
that a portable ventilator is not medically reasonable and necessary for the enrollee. The record indicates that
the enrollee has a diagnosis of chronic respiratory failure from chronic obstructive pulmonary disease. The
record does not indicate that the enrollee is hypercarbic. The provided primary source documentation does not
contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee
could be treated with a BiPAP machine with average volume-assured pressure support capability. Our
physician reviewer found that the enrollee's condition does not meet Medicare criteria for a portable ventilator.
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 portable ventilator have not been met. Therefore, we decided that the Plan
does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the acute inpatient hospital care to be provided after surgery.  You asked the Plan to pre-approve acute inpatient hospital care. You say that this inpatient medical care is medically necessary following the enrollee's surgery. The Plan denied your request. The Plan says the criteria for coverage of inpatient admission have not been met.  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 pre-approve acute inpatient hospital care. 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.   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 have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care to be provided after surgery.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra.

You asked the Plan to pre-approve Xiidra. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the requested drug is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xiidra.

Benefits for Xiidra may be available under Medicare Part D. Contact the Plan that administers Part D benefits
for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.  You asked the Plan to pre-approve a SNF admission. You say that it would not be a safe discharge. You say that the enrollee would be returning home to an individual that is limited in their ability to care for the enrollee. The Plan denied your request. The Plan says the enrollee is receiving adequate services in their current situation. The Plan also says that a transfer to a SNF is 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 pre-approve a SNF admission. Our reviewer says that the SNF admission is not medically necessary.. Our physician reviewer found the enrollee is receiving medication management for adjustments that have been made recently. The reviewer found that the is currently receiving appropriate medical management and therapy in the inpatient rehabilitation facility (IRF) and does not require a SNF transfer. Therefore, the reviewer found that the SNF admission 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 a SNF admission have not been met. Specifically, the file shows that the enrollee is currently receiving appropriate medical management and therapy in the inpatient rehabilitation facility. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
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 you do not need intensive therapies, consisting of at least 3 hours of therapy per day
at least 5 days per week with multidisciplinary approach to daily therapy. Your rehab needs can be safely met
in an alternate and lower intensity setting such as in a skilled nursing facility or home with 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 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for physician services, home test materials and
equipment for International Normalized Ratio (INR) monitoring provided from November 8, 2020, to March
28, 2021.
You asked the Plan to waive cost share. You say that you do not believe this billing is correct. The Plan denied
your request. The Plan says this cost share was charged based on the services and supplies provided and the
Plan contract agreement. We partially overturned the Plans denial. The Plan requested a reopen and
stated that we did not apply the correct contract language.
The Plan is correct in this case. 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 cost share for each service provided and for medical supplies provided. The
coinsurance was assessed correctly for the supplies provided. The Physician copayments are for the processing
and reading of the INR data collected and submitted for each date of service.
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 cost share charged for physician services, home test materials and equipment for
International Normalized Ratio (INR) monitoring (G0249 x4) provided from November 8, 2020, to March 28,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group three power wheelchair and accessories.

You asked the Plan to pre-approve a group three power wheelchair and accessories. 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. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to:

1. A neurological condition;
2. Myopathy; or
3. Congenital skeletal deformity.

The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
group three power wheelchair and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested item.
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 pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 2 systems (E2311) expandable controller (E2377) and expandable controller harness (E2313).

You asked the Plan to pre-approve the upgraded electronics. You say that all of your documentation follows the attached Medicare guidelines. The Plan denied your request. The Plan says the approved power options come with their own switches and there is no medical need to control these power options through the joystick.

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 upgraded electronics. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found although there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is no medical need to control these power options through the joystick. The review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 

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 upgraded electronics have not been met. Therefore, we decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 2 systems (E2311) expandable controller (E2377) and expandable controller harness (E2313).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care admission and services.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested inpatient hospital
admission is medically necessary. The Plan denied your request. The Plan says the requested inpatient hospital
admission does not meet criteria.
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 pre-approve acute inpatient hospital care. 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 enrollee is undergoing a planned lumbar laminectomy. The enrollee is
medically stable and has been provided medical clearance to undergo this elective procedure. The procedure is
currently approved as an ambulatory procedure. There is no documentation provided to support the expectation
the enrollee will require a greater than 2 midnight stay.
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 have not been met. Therefore, we decided that the
Plan does not have to pre-approve acute inpatient hospital care admission and services
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the polysomnography services (code 95810-26) provided to
the enrollee on April 26, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare coverage criteria were not met.
We overturned the Plans denial indicating as these services were ordered by a Plan provider they should
be covered. The Plan requested a reopen and stated the enrollee is not being held liable for these services and
the issue was with the billing of the service.
The Plan stated this claim denied because this service should be reported within one year of a comprehensive
sleep evaluation based on the Medicare guidelines. The Plan states Medicare requires an order from the
provider who evaluates or treats the beneficiary. This is further supported by the Federal Code of Regulations,
42 CFR  410.32, which explains all diagnostic tests must be ordered by the physician who is treating the
beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical
problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not
ordered by the physician who is treating the beneficiary are not reasonable and necessary. The entity submitting
the claim must provide the documentation that it receives from the ordering physician or non-physician
practitioner. The Plan states the enrollees claim history does show a visit with the referring physician. The
medical records did not include a copy of a referral or an order for the diagnostic test. Therefore, it cannot be
confirmed that an in-person evaluation was done within one year of the sleep study, nor that an order was given
by the referring physician listed to have this service performed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes and when necessary, submit
the documentation required by Medicare to demonstrate the services provided were ordered appropriately and
billed appropriately. In this case, the medical records do not show a valid physician order, nor do they show the
enrollee was seen by the ordering physician listed prior to the testing being provided and/or billed. Medicare
rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay
for the polysomnography (code 95810-26) provided to the enrollee on April 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for inpatient admission for shoulder surgery.
You asked the Plan to provide coverage for acute inpatient hospital care. You say that inpatient admission was
medically necessary. The Plan denied your request. The Plan says Medicare criteria for inpatient care are not
met. We overturned the Plans denial. The Plan requested a reopen and stated that we did not apply
the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for inpatient
admission for right reverse total shoulder replacement surgery. Our Physician Reviewer determined
the requested inpatient admission for right reverse total shoulder replacement surgery was determined to be
medically reasonable and necessary. The Plan argues the shoulder procedure is not on the Inpatient Only list.
The Plan states that, despite the enrollee's medical history, there was no reason that the enrollee could not be
monitored within the ambulatory/observation system, and that the attending physician could change to inpatient
status based upon any operative or post-operative concerns.
The Plan is correct in this case. The enrollee was a 75-year-old woman with a past medical history of ischemic
heart disease, heart failure, hypertension, and breast cancer. A right total shoulder replacement was planned and
approved. The clinical documentation does not demonstrate that the admitting physician reasonably expected
that the necessary hospital care would span at least two midnights. It is not documented that the enrollee had
serious, uncontrolled medical conditions that would require inpatient admission. Medicare coverage criteria
were not met.
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 have not been met. Therefore, we decided that the
Plan does not have to provide coverage for inpatient admission for shoulder surgery.