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

 We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's upper extremity strength and function are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options.  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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a neurologic disorder with functional deficits. He meets criteria for use of a power mobility device. However, the requested accessories are not medically necessary as he does have use of his hands and can operate and control the power options using the switches that are included in the basic wheelchair. The requested accessories are not medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.
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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.  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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for pneumonia and hypoxemia. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 pay for anesthesia services (99135) provided July 23, 2021.  You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed code is not separately payable.  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 find that CPT code 99135 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, this service has a status of "B" and payment is always bundled with another service. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (99135) provided July 23, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Ferahme.  You asked the Plan to pre-approve Ferahme. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been met.  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 Ferahme. Our reviewer says that this drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of Ferrlicit, Infed, or Venofer before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s) would likely be less effective and/or likely have adverse effects 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 Ferahme have not been met. Therefore, we decided that the Plan does not have to pre-approve Ferahme.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the resin-based composite (D2330) provided on October 20, 2021.  You asked the Plan to pay for the resin-based composite. You say that you are on a fixed income and only go to the dentist once per year to keep the costs down. 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 pay for the resin-based composite (D2330) provided on October 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for dental services provided on July 27, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for dental services. You say that your normal dentist office was closed due to Covid-19. The Plan denied your request. The Plan says services must be provided by an in-network provider.  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 dental services provided on July 27, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee.  You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery has not been demonstrated in the peer-reviewed literature.  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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Bone marrow aspirate remains experimental. More research is needed to show safety and efficacy of bone marrow aspirate for use as bone graft material. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a surgical procedure for isolation of a tooth with a rubber dam (D3910) and canal preparation and fitting of a preformed dowel or post (D3950) for tooth #12.  You asked the Plan to pre-approve the dental services. You say that these services are necessary, and you cannot afford them. The Plan denied your request. The Plan says these services are part of the previously approved root canal (D3320) and prefabricated post and core (D2954) and are not separately billable.  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. In addition, Medicare rules say that providers must report services correctly. Providers must report services with the appropriate Current Procedural Terminology (CPT) codes.  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 surgical procedure for isolation of a tooth with a rubber dam (D3910) and canal preparation and fitting of a preformed dowel or post (D3950) for tooth #12. Our reviewer says that the file shows that the Plan has already approved a root canal (D3320) and a prefabricated post and core (D2954). Part of the root canal treatment includes placement of a rubber dam as the standard of care. Also, the procedure for the prefabricated post and core includes the preparation and fitting of the post/core. Separate procedures and fees for placement of the rubber dam and canal preparation for the post are not covered expenses, as the cost of these services are included in the root canal and prefabricated post and core services, which have already been approved by the Plan. It is not necessary to approve these services as separately billed procedures.  We looked at the physician's review, the file, and the Plan's rules. Based on this information, we decided that the rules for coverage of these services are not met. Specifically, these services are part of previously approved services and are not billable as separate services. Please note that while the Plan does not have to pre-approve the rubber dam and canal preparation as separate services, they are included as part of the root canal and prefabricated post and core services which were previously approved by the Plan. It is inappropriate to bill for these services twice. If you are billed separately for these services after the root canal and post and core are provided, you may contact the Plan again regarding this issue. Generally, enrollees should not be held liable for billing errors submitted by contracted (in-network) providers. Therefore, we decided that the Plan does not have to pre-approve a surgical procedure for isolation of a tooth with a rubber dam (D3910) and canal preparation and fitting of a preformed dowel or post (D3950) for tooth #12.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Feraheme.  You asked the Plan to pre-approve Feraheme. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been met.  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 Feraheme. Our reviewer says that this drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of Ferrlicit, Infed, or Venofer before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s) would likely be less effective and/or likely have adverse effects 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 Feraheme have not been met. Therefore, we decided that the Plan does not have to pre-approve Feraheme.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the acute inpatient hospital care for total hip arthroplasty (CPT code 27130), for the enrollee.  You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is necessary. The Plan denied your request. The Plan says the enrollee is undergoing a planned left hip arthroplasty. The Plan states the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The Plan states the planned procedure listed under CPT code 27130 is not listed on the CMS Inpatient Only List and the procedure is currently approved as an ambulatory procedure. The Plan states there is no documentation provided to support the expectation the enrollee will require a greater than two (2) midnight stay. The Plan states if the enrollee experiences any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with updated clinical information.  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 review indicates that the record did not show that at the time of inpatient admission the admitting physician reasonably expects that the enrollee's necessary hospital care will span two midnights.  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 for total hip arthroplasty (CPT code 27130), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that the enrollee had a medical decline and lives alone. You state the enrollee is afraid they will not be able to return home. The Plan denied your request. The Plan says the enrollee's records received do not indicate they need an intensive therapy program with multiple visits from a rehabilitation doctor per week. You can safely receive the services you need in other settings, for example: a skilled nursing facility, home with home health and home physical therapy.  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 based on the medical records provided 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 does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. There is no documentation that the enrollee requires the intensive rehabilitation therapy program provided in an IRF. Care at the skilled nursing facility level appears to be appropriate 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia.  You asked the Plan to pre-approve Prolia. You say that this drug is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.  The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.  In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia.   Benefits for Prolia 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for arthrocentesis and does not have to waive the coinsurance for Medicare Part B drugs provided on April 23, 2021.  You asked the Plan to waive the copayment for arthrocentesis and to waive the coinsurance for Medicare Part B drugs. You say that this was an approved procedure but are now being charged $350. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  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 $45 copayment for services obtained by a specialist. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs.  You received arthrocentesis on April 23, 2021. Therefore, you are responsible to pay the $45 copayment.   You received Medicare Part B drugs on April 23, 2021. The total allowed amount is $1,536.96 and 20% of that is $307.39.   The total amount you owe is: $352.39.    You have been asked to pay the total amount of $352.39 for arthrocentesis and Medicare Part B drugs. arthrocentesis and to waive the coinsurance for Medicare Part B drugs falls within the physician/practitioner services, including doctor's office visits Medicare Part B prescription drugs 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 arthrocentesis and does not have to waive the coinsurance for Medicare Part B drugs provided on April 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve enteral nutrition (B4150).  You asked the Plan to pre-approve enteral nutrition. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for the requested item have not been met.  The Plan must follow Medicare rules. Medicare rules say that enteral nutrition is covered for an enrollee who requires feedings via an enteral access device to provide sufficient nutrients to maintain weight and strength.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of enteral nutrition have not been met. Specifically, the provided medical documentation does not support that the enrollee requires feedings via an enteral access device. Therefore, we decided that the Plan does not have to pre-approve enteral nutrition (B4150).
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve treatment with Eylea (J0178).  You asked the Plan to pre-approve Eylea. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says that step therapy rules for the requested drug have not been met.  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 Eylea. Our reviewer says that the requested treatment is medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial of drug Avastin before they will approve the requested drug. The enrollee has not tried and failed the required drug; however, the documentation provided by the ophthalmologist supports that Avastin would potentially be less effective and/or would potentially 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 Eylea have been met. Therefore, we decided that the Plan has to pre-approve treatment with Eylea (J0178).   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.