Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
You asked the Plan to pre-approve the compression stockings. You say that please approve the doctor's request
for compression stockings to be provided to you. The Plan denied your request. The Plan says this item is not
covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6533.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Over-the Counter Drug Allowance benefit.

You asked the Plan to reimburse you for the Over-the Counter Drug Allowance benefit. The Plan denied your request. The Plan says orders are limited to one per quarter. Quarterly allowances cannot be carried over to another quarter.

The contract with the Plan says that the Over-the Counter Drug Allowance benefit orders are limited to one per quarter. Quarterly allowances cannot be carried over to another quarter. 

We looked at the file and the Plan's rules. Based on this information, we decided that Medicare rules for coverage of the Over-the Counter Drug Allowance benefit have not been met. Specifically, the Over-the Counter Drug Allowance benefit allowance cannot be carried over to another quarter. Therefore, we decided that the Plan does not have to reimburse you for the Over-the Counter Drug Allowance benefit.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 36 transportation trips.
You asked the Plan to pre-approve an additional 36 transportation trips. You say that you need transportation for medical appointments. The Plan denied your request. The Plan says you have utilized the maximum number of transportation trips allowed per year.
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 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 have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve an additional 36 transportation trips
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the biopsy of oral tissue, soft (D7286). 
 
You asked the Plan to pre-approve the dental service. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says this service is not listed as a covered 
benefit and is therefore, 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. 
 
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 the 
biopsy of oral tissue, soft (D7286).
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, per statute mile (A0425) provided April 13, 2021.
You asked the Plan to pay for the non-emergency ambulance transport. You say that the enrollee's transport should be covered. The Plan denied your request. The Plan says information provided at the time of the appeal does not support ambulance transport.
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 non-emergency ambulance transport. Our reviewer says that the non-emergency ambulance transport was not medically necessary. Our physician reviewer found that the documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this enrollee on April 13, 2021. The documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on April 13, 2021. The documentation did not support that the ambulance transport on April 13, 2021, was medically reasonable and necessary for the patient. 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 non-emergency ambulance transport have not been met. 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, per statute mile (A0425) provided April 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the IRF services are medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare coverage criteria for the IRF services.
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 there are no complex nursing or rehabilitation needs.
There is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this member 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prefabricated oral device/appliance (E0485).
You asked the Plan to pre-approve the oral device. You say that you request an appeal for a fitted mouth guard due to need for adherence to use of CPAP device. The Plan denied your request. The Plan says the requested mouth guard is not covered by Medicare because it is considered an optional accessory to your CPAP machine.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the mouth guard have not been met. Therefore, we decided that the Plan does not have to pre-approve prefabricated oral device/appliance (E0485).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for a continuous glucose monitor and supplies.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says it has been verified that there are in-network providers available.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral out-of-network for a continuous glucose monitor and supplies
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 you would like reconsideration because the IRF admission is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare coverage criteria for the IRF admission.
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 there are no complex nursing or rehabilitation needs. There is no documented need
for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this member 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: 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 enrollee would benefit from the highest level of rehabilitation to regain his maximum function. The Plan denied your request. The Plan says the enrollee is near his pre-admission baseline.
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 respiratory failure, pneumonia and pulmonary edema. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visit (99245) to be provided by an
out-of-network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that you were told your cataract needed to be
removed and you would rather have someone that is young perform that type of surgery. The Plan denied your
request. The Plan says enrollee's must receive their medical services from an in-network provider with the
exception being urgent or emergent services. Non-emergent services with non-contracted providers require
prior authorization before services being rendered.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
the outpatient office visit (99245) to be provided by an out-of-network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve Vertiflex. You say that the enrollee has failed conservative treatment and
Vertiflex would provide significant clinical and quality of life benefits. The Plan denied your request. The Plan
says the denial of authorization for this service is correct, because Vertiflex is experimental/investigational.
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 Vertiflex. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Vertiflex device is experimental, more research is needed to show its 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a third level of facet joint injections (64495).
You asked the Plan to pre-approve a third level of facet joint injections. You say that this is medically necessary. The Plan denied your request. The Plan says this cannot be approved in a single session.
The Plan must follow Medicare rules. Medicare rules say that one to two levels of facet joint interventions, either unilateral or bilateral, are allowed per session per spine region. We looked at the file and Medicare rules. Only two levels are allowed per session of facet joint intervention. Based on this information, we decided that Medicare rules for coverage of a third level of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve a third level of facet joint injections (64495).
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
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 the enrollee does not require services at the LTACH that are not available at the acute care hospital where currently receiving 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 the LTACH services have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into a LTACH is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules state that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. If a wheelchair has an electrical connection device described by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power standing feature, it will be denied as non-covered. If an attendant control (E2331) is provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered. You can find this information in the Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that 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 require the intensity of services provided at an IRF. Specifically, you are
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a network exception for cardiovascular telemetry
(93229) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a network exception for cardiovascular telemetry. You say that the enrollee
needs this. The Plan denied your request. The Plan says this is available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that while the Plan covers out-of-network services, there is a higher cost share for these services.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a network exception for cardiovascular telemetry (93229) to be provided by an out-of-network (OON)
provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health aide visits provided from October 18, 2020, through October 31, 2020.
You asked the Plan to pay for the home health aide visits. You say that these services should be paid. The Plan denied your request. The Plan says the services were provided by an agency that is not enrolled in the Medicare program.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the home health aide visits provided from October 18, 2020, through October 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incisional biopsy of oral tissue - soft (D7286), therapeutic parenteral drug, single administration (D9610), the initial 15 minutes of deep sedation (D9222), and the additional 15 minutes of deep sedation (D9223) provided on June 7, 2021.

You asked the Plan to pay for the dental services. You say that you have to have oral surgery to remove a cyst on the upper front part of your mandible. You say that this was a medically necessary procedure. You also say that these services should be covered under your medical plan. The Plan denied your request. The Plan says that the dental services you received are 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the incisional biopsy and therapeutic parenteral drug are not among those covered under this benefit. Additionally, deep sedation is not covered unless it is provided in conjunction with covered services. Therefore, we decided that the Plan does not have to pay for the incisional biopsy of oral tissue - soft (D7286), therapeutic parenteral drug, single administration (D9610), the initial 15 minutes of deep sedation (D9222), and the additional 15 minutes of deep sedation (D9223) provided on June 7, 2021.