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

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not require daily skilled nursing or therapy services on an inpatient basis.  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 services. Our physician reviewer found that you are non-ambulatory presently. You are at a moderate assist level for transfers and minimal assist for dressing. You do not require the services of a skilled nurse or qualified therapist on a daily basis to provide medically necessary treatment. You do not require services 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) 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 will clearly benefit from IRF services to optimize her level of functioning prior to returning home. The Plan denied your request. The Plan says the requested IRF services are not medically necessary.  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 that 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. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: 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 will clearly benefit from IRF care to optimize her level of functioning prior to returning home. The Plan denied your request. The Plan says under Medicare, the requested IRF care is not medically necessary.  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 that 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. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on March 26, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.      We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in a skilled nursing facility setting and should have been billed with POS code 31. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466) for the enrollee.  You asked the Plan to pre-approve the home ventilator. You say that the ventilator is to be used for the treatment of chronic obstructive pulmonary disease (COPD). The Plan denied your request. The Plan says the request for a home mechanical ventilator set in average volume-assured pressure support (AVAPS) mode that could be delivered by bilevel positive airway pressure (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 the home ventilator. Our physician reviewer found a home ventilator is not medically necessary. This enrollee has COPD, with a recent exacerbation requiring hospitalization. A venous blood gas while acutely ill suggested carbon dioxide (CO2) retention, but there is no arterial blood gas (ABG) done while awake and stable as an outpatient. Medicare does not cover a ventilator when used as BiPAP, and the AVAPS mode can be provided via BiPAP, at less cost to 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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Dexilant for the enrollee.  You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this self-administered drug does not fall under Part B 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 Dexilant for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve LTACH services.  You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee is receiving appropriate inpatient acute care in the current facility and is unstable for transfer at this time.  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 there is no documentation provided indicating medical necessity for admission to a LTACH.  The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a referral to an out-of-network thoracic surgeon.  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 services are available from network providers.  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 to an out-of-network thoracic surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a shower chair.  You asked the Plan to pre-approve a shower chair. You say that your mother's mobility is declining due to her knees. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.   While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Soriatane capsules.  You asked the Plan to pre-approve self-administered drug. You say that you are appealing with supporting records. 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 benefits.  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 Soriatane capsules.   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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Freestyle lancets.  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 services are available from the preferred providers.  The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to specific providers for durable medical equipment and supplies.  We looked at the file and Medicare rules. The requested diabetic testing supplies are from a non-preferred provider with the Plan. The services are available from the Plan's preferred providers. Therefore, we decided that the Plan does not have to pre-approve Freestyle lancets.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the resin-based composite (D2392) provided on June 28, 2021.  You asked the Plan to pay more for the resin-based composite. You say that you would like to appeal this denial and have the bill paid. The Plan denied your request. The Plan says your calendar year maximum has been met.  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 Plan offers a $1,000 combined allowance for supplemental preventive and comprehensive dental services every year. The contract says that you are responsible for any amount over and above the allowance amount. The record shows that you met the annual maximum benefit while processing this claim for the June 28, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the resin-based composite (D2392) provided on June 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Botox (J0585).  You asked the Plan to pre-approve Botox. You say that both the referring neurologist and specialist recommend Botox as the best care for the enrollee's diagnosis. The Plan denied your request. The Plan says Botox is a non-preferred product, and the enrollee has not tried any of the preferred agents. The Plan also says that the enrollee does not have any stated contraindications to the preferred products.  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 Botox. Our reviewer says that Botox (J0585) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee has not tried and failed the required drug, Xeomin (IncobotulinumtoxinA). Our reviewer also found that the documentation is insufficient to support that Xeomin (IncobotulinumtoxinA) 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 Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox (J0585).
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services provided on August 3, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.  The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation.    We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Specifically, the record shows that the claim was billed with primary diagnosis code, I70.92. This code has a code first note, which means it is a manifestation code and must be sequenced after an etiology code. 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 pay for the services provided on August 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on May 6, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an outpatient hospital setting and should have been billed with POS code 22. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services (G0483) provided on June 9, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed".  We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show that 22 or more drug classes were tested on the date of service in question. 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 pay for the drug testing services (G0483) provided on June 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve replacement of replaceable part of semi-precision or precision attachment (D5867) for teeth # 23 and 26, and overdenture (D5863).  You asked the Plan to pre-approve the dental services. You say that the enrollee has existing implants for teeth # 23 and 26. You also say that the enrollee needs an implant denture to properly restore their bite for chewing food. The Plan denied your request. The Plan says replacement of replaceable part of semi-precision or precision attachment is not listed as a covered service. The Plan also says that overdenture is not listed as a covered service either.  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, replacement of replaceable part of semi-precision or precision attachment and overdenture are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve replacement of replaceable part of semi-precision or precision attachment (D5867) for teeth # 23 and 26, and overdenture (D5863).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a shoulder-arm orthosis (L3960) provided on April 21, 2021.  You asked the Plan to pay for a shoulder-arm orthosis. You say that the item at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for durable medical equipment have not been met.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in the patient's medical record adequately supports the medical necessity for the item.  The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the provided medical records do not discuss the item at issue.  The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a shoulder-arm orthosis (L3960) provided on April 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pregnancy test provided on May 20, 2021, billed with code 84703.  You asked the Plan to pay for the pregnancy test. You say that this claim should be paid in full. The Plan denied your request. The Plan says it was decided to approve payment for the presumptive drug testing. However, there is not support in the records for the gonadotropin testing.  The Plan must follow Medicare rules. Medicare rules say that providers must only bill for services actually rendered.  In addition, while orders need not be signed by the treating provider, there must be clear evidence of the intent to perform testing.  In this case, the lab order, signed by the physician, does not include any request for a pregnancy test. The results also do not appear to include a result for this test. As such, this cannot be paid. Therefore, we decided that the Plan does not have to pay for the pregnancy test provided on May 20, 2021, billed with code 84703.