Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the longer you go without physical therapy the more your problem will worsen. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.  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. Our physician reviewer found your breathing status is more stable and should only require additional short-term acute care that can be safely administered at the current facility. You do not require services at the LTACH that are not already available at the current facility. Transfer to a lower level of care may be considered when you have completed treatment.  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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trelegy Ellipta.

You asked the Plan to pre-approve self-administered drug. You say that this drug is medically necessary. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug coverage.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 Trelegy Ellipta.

Benefits for self-administered drug 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 and 22870).
You asked the Plan to pre-approve the insertion of stabilization device (22869 and 22870). You say that the
member has failed more than 6 months of conservative approaches to treatment. You say that this treatment is
considered safe and effective, and the necessary coverage should be provided. The Plan denied your request.
The Plan says there are not enough studies to show Vertiflex Superion is safe and effective to treat back pain.
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 of stabilization device
(22869 and 22870). Our reviewer says that the requested items/services are not considered medically
reasonable and necessary in this case. Our physician reviewer found that interspinous process distraction
devices remain experimental. More research is needed to show safety and efficacy.
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 of stabilization device (22869 and 22870) have not been met.
Therefore, we decided that the Plan does not have to pre-approve the insertion of stabilization device (22869
and 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the endodontic therapy, molar tooth (excluding final restoration) (D3330) and limited oral evaluation - problem focused (D0140) provided June 23, 2021.  You asked the Plan to pay for the root canal and limited oral exam. You say that you were referred to this provider. The Plan denied your request. The Plan says these services are not covered because the provider who rendered them has opted out of Medicare.  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 root canal and limited oral exam when you see any licensed dental provider who accepts Medicare patients in the United States and has not opted out of Original Medicare  We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of the root canal and limited oral exam have not been met. Therefore, we decided that the Plan does not have to pay for the endodontic therapy, molar tooth (excluding final restoration) (D3330) and limited oral evaluation - problem focused (D0140) provided June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve surgical extractions (D7210) to be provided by an oral surgeon.  You asked the Plan to pre-approve services from an oral surgeon. You say that these services are necessary. The Plan denied your request. The Plan says dental services provided by anyone other than a participating general dentist are not covered. Therefore, the request for dental care to be provided by an Oral Surgeon is denied.  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 requires that supplemental dental care be performed by a participating general dentist.  Though the Plan offers a dental benefit in excess of Medicare coverage, services performed by providers other than participating general dentists are not covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical extractions (D7210) to be provided by an oral surgeon.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.  You asked the Plan to pre-approve SNF admission. You say that you need continued monitoring for blood pressure due to adjustments in medications. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of SNF care.  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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you have tolerated inpatient rehab services and continue to improve with daily skilled nursing and/or skilled therapy services. There is no indication that transfer to a skilled nursing facility is required.  You can continue to receive skilled rehab services at the current 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 inpatient rehab facility. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc.

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 drug is not eligible for a tier exception.

The Plan must follow Medicare rules. Medicare rules say that drugs covered under Part B are not eligible for a Part D tier exception. 

We looked at the file and Medicare rules. The requested Orthovisc is covered under Part B Medicare and is therefore not eligible for a Part D tier exception. Therefore, we decided that the Plan does not have to pre-approve Orthovisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) and unspecified preventive procedure, by report (D1999) provided June 7, 2021.  You asked the Plan to pay for the crown and unspecified preventative procedure. You say that you were told you would be reimbursed $500. The Plan denied your request. The Plan says these services are not covered because the provider has opted out of Medicare.  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 crown and unspecified preventative procedure when see any licensed dental provider who accepts Medicare patients in the United States and has not opted out of Original Medicare.  We looked at the file and Medicare rules. The provider who rendered the services has opted out of Medicare. Based on this information, we decided that the Plan's rules for coverage of the crown and unspecified preventative procedure have not been met. Therefore, we decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) and unspecified preventive procedure, by report (D1999) provided June 7, 2021.   Your complaint about potentially being misinformed by a Plan representative 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: 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 SNF admission.. You say that the enrollee needs to be discharged to a skilled nursing facility (SNF) for nursing care and physical therapy to build up strength. You say that the enrollee currently resides in an assisted living facility and has no strength to care for themself. You also say that it is necessary for the enrollee to regain their strength before returning to assisted living. The Plan denied your request. The Plan says the requested admission 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 SNF admission. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 admission. have not been met. Specifically, the file does not show that the enrollee requires daily skilled services. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for mental health psychotherapy (90834).  You asked the Plan to pay for mental health psychotherapy. You say that the enrollee has developed a trusting relationship with you and transferring the enrollee to a new therapist would be difficult on the enrollee's mental health. The Plan denied your request. The Plan says it is past 90 days since the effective date for the enrollee with this Plan, this provider is not a network provider, there are in-network providers that can provide psychotherapy services, and the notes sent did not show a plan to change to an in-network provider, or why it was medically necessary for the enrollee to continue to treat with this provider.  Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for 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 mental health psychotherapy have not been met. Therefore, we decided that the Plan does not have to pay for mental health psychotherapy (90834).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a stair lift (stair glide) and wheelchair ramp.  You asked the Plan to pre-approve stair lift and wheelchair ramp. You say that you need the stair lift to get upstairs and need the wheelchair ramp to get into your house. The Plan denied your request. The Plan says these items are not covered by Medicare.  The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.  While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Furthermore, the wheelchair ramp at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a stair lift (stair glide) and wheelchair ramp.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), and ground mileage (A0425) provided on July 17, 2021.  You asked the Plan to pay for the transportation services. You say that the transportation services were necessary. The Plan denied your request. The Plan says the non-emergency transportation is not medically necessary.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   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 transportation services. Our reviewer says that the transportation services are not medically necessary. Our physician reviewer found the provided documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for the enrollee on July 17, 2021. The documentation does not support that the enrollee needed the expertise, services, life-saving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on July 17, 2021. The documentation did not support that the ambulance transport on July 17, 2021 was medically reasonable or necessary for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transportation services have not been met. Specifically, the file does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for the enrollee on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), and ground mileage (A0425) provided on July 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve genicular nerve block, represented by CPT code 64640, and a Coolief genicular nerve radiofrequency ablation (RFA) procedure, represented by CPT code 64624.  You asked the Plan to pre-approve genicular nerve block and a Coolief genicular nerve radiofrequency ablation (RFA) procedure. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve genicular nerve block and a Coolief genicular nerve radiofrequency ablation (RFA) procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has bilateral knee osteoarthritis. The enrollee takes Diclofenac, Motrin, Flexeril and Tramadol for pain. The enrollee has tried Physical therapy. The enrollee had a right knee genicular block with 60% relief. This is considered an experimental/ investigational procedure. Therefore, the request is considered not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular nerve block and a Coolief genicular nerve radiofrequency ablation (RFA) procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve block, represented by CPT code 64640, and a Coolief genicular nerve radiofrequency ablation (RFA) procedure, represented by CPT code 64624.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).  You asked the Plan to pre-approve the insertion of stabilization device (22869). The Plan denied your request. The Plan says services that are not medically necessary are not covered.  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 of stabilization device (22869). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that interlaminar distraction devices are experimental. More research is needed to show safety and efficacy of the devices.    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 of stabilization device (22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided to the enrollee from March 18, 2021 to June 12, 2021.  You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim was not submitted with the required Q code.  The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.  We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim was submitted to the Plan without the required Q code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from March 18, 2021 to June 12, 2021.   We note that it appears a corrected claim was submitted directly to Maximus during the review of this case. We cannot act on or process claim corrections. Corrected claim information may be submitted directly to the Plan for further review. We are only permitted to make a decision based on the claim information reviewed by the Plan for payment. Please submit any corrections or additional claim information directly to the Plan.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Contour brand test strips (A4253).  You asked the Plan to pre-approve Contour brand test strips. You say that the Contour brand test strips are medically necessary. The Plan denied your request. The Plan says the requested brand of test strips are not covered under the plan contract.  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers.  We looked at the file and Medicare rules. No clinical documentation was provided to show that the plan preferred test strip brand would be unsafe or ineffective for this enrollee. Based on this information, we decided that Medicare rules for coverage of Contour brand test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Contour brand test strips (A4253).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve post removal (D2955) for tooth # 3.
You asked the Plan to pre-approve the dental service. You say that you were denied for root canal surgery. You
also say that you have needed this surgery for a while. The Plan denied your request. The Plan says post
removal 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 requested post removal is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve post
removal (D2955) for tooth # 3.