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

 We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supply allowance (K0553), provided on March 18, 2021.  You asked the Plan to pay for the CGM supply allowance. You say that the items are medically necessary. The Plan denied your request. The Plan says the documentation submitted did not sufficiently support the billed supply code; nor did documentation indicate the provider discussed the need for the billed supply code.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The documents submitted do not indicate medical necessity or that the provider discussed the need for this item. 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 the continuous glucose monitor (CGM) supply allowance (K0553), provided on March 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve therapeutic facet joint injection services.  You asked the Plan to pre-approve therapeutic facet joint injection services. You say that this is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says there is no evidence as to why radiofrequency ablation cannot be performed at this time as required by Medicare coverage criteria.  The Plan follows Medicare rules. Medicare rules say that there must be documentation of why the patient is not a candidate for radiofrequency ablation before therapeutic facet joint procedures are approved.  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 therapeutic facet joint injection services. Our reviewer says that the requested services are not medically reasonable and necessary according to Medicare rules. Our physician reviewer found there is no role for an ongoing series of intra-articular facet injections. The standard of care according to Medicare rules is to perform radiofrequency ablation (RFA) of the medial branches after 2 successful diagnostic blocks. There is no documentation as to why RFA services would not be reasonable at this time. 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 therapeutic facet joint injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve therapeutic facet joint injection services.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to provide coverage for additional mileage for routine transportation.  You asked the Plan to provide coverage for additional mileage for routine transportation. You say that you need an extension of mileage for a doctor's appointment. The Plan denied your request. The Plan says the requested amount of mileage exceeds the limit listed by the Plan. The mileage from your home to the surgery office avoiding tolls, highways, and ferries is a total of 118 miles, which is 68 miles over your allowed benefit.  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.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, the file shows that the mileage from your home to the surgery office avoiding tolls, highways, and ferries is a total of 118 miles, which is 68 miles over your allowed benefit. Therefore, we decided that the Plan does not have to provide coverage for additional mileage for routine transportation.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six (6) additional PT visits.
You asked the Plan to pre-approve six (6) additional PT visits. The Plan denied your request. The Plan says
additional PT is not medically necessary based on the Medicare Local Coverage Determination (LCD) L33631,
Outpatient Physical Therapy (PT) and Occupational Therapy (OT).
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 six (6) additional PT visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally
accepted as specific and effective therapy for your condition beyond what was approved by the health Plan.
You have had prior extensive therapy for this condition and the records do not demonstrate that the unique
skills of a professional therapist are required to safely and effectively provide treatment, that the services can
be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have
been instructed in a home exercise program. The requested services are not part of a maintenance program, are
the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or
deliver a program to maintain your current condition or to prevent or slow further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of six (6) additional PT visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve six (6) additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (62320) provided September 6, 2021.
You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due and the amount of payment.
We looked at the file and Medicare rules. No clinical records were submitted to support the services. Based on
this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore,
we decided that the Plan does not have to pay for injections (62320) provided September 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (62320) provided on July 26, 2021.

You asked the Plan to pay for injections. You say that this treatment is part of a comprehensive pain
management program. The Plan denied your request. The Plan says this is not supported with medical records.

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 62320 is injection(s), of diagnostic or therapeutic
substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances,
including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without
imaging guidance.

We find that CPT code 62320 is not supported in the medical record. Specifically, no medical records
documenting this service have been submitted. Based on this information, we decided that Medicare rules for
coverage of injections have not been met. Therefore, we decided that the Plan does not have to pay for
injections (62320) provided on July 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on October 18, 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 are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.
We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services
were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion
therapy rendered on October 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Foresee Home-Visual Assessment Tech Support with Instruction (code 0379T) for a 12-month duration.
You asked the Plan to pre-approve this service. You say that this service is approved by Medicare and medically necessary for the enrollee. The Plan denied your request. The Plan says for this procedure, the provider performs examination of the visual field of each eye. They report this code if there is concurrent real time data analysis and accessible data storage with a patient-initiated data transmission to remote surveillance center for up to 30 days and there is technical support and monitoring of the patient and data as per the direction of the provider. While this service and device are assigned a temporary code by Medicare, this request is for 12 months of use. The Plan states that services or devices assigned "T" codes are intended to be used for data collection to substantiate more widespread usage or to provide documentation for the Food and Drug Administration (FDA) approval process. T-code procedures are considered experimental or investigational and are not covered by Medicare.
The Plan is correct in this case. Medicare does not pay for experimental services or devices. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 provider in this case is not a network provider with the Plan. The service requested is not a covered services based on Medicare guidelines. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve Foresee Home-Visual Assessment Tech Support with Instruction (code 0379T) for a 12-month duration for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 24, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.

Therefore, we decided that the Plan does not have to pay for the office visit provided on September 24, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that it is felt that SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not require skilled services on a daily 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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute care on 2/9/2022 with shortness of breath with mild exertion for several weeks. She was found to have new onset atrial fibrillation. She was put on Cardizem, Lovenox, and a Holter monitor. She was also found to have acute pneumonitis. The enrollee requires contact-guard assistance with ambulation and sit to stand. The patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The patient's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this patient does not require the necessary services on an inpatient basis, in a skilled nursing facility 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 the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Injectafer.  You asked the Plan to pre-approve Injectafer. The Plan denied your request. The Plan says the enrollee has not tried and failed Infed and Venofer.   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 Injectafer. Our physician reviewer found that in this case, the record indicates the enrollee has iron deficiency anemia and stage IV chronic kidney disease. The requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for oximetry (94761) and albuterol ipratropium (J7620) provided on January 16, 2021.  You asked the Plan to pay for oximetry and albuterol ipratropium. You say that these codes were covered by Medicare and were medically necessary. The Plan denied your request. The Plan says the denial of payment for these services is correct, because code 94761 exceeds the Medically Unlikely Edit (MUE) value for this code and code J7620 is not billable to the Plan.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. Medicare rules say that code J7620 has a Status Indicator of M, resulting in returning the claim to the provider except is specified circumstances.  In this case, the MUE for CPT code 94761 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Furthermore, albuterol ipratropium code J7620 has a status indicator of M resulting in a claim disposition of Return To Provider. You can resubmit the claim once the problems are corrected. Based on this information, we decided that Medicare rules for coverage of oximetry and albuterol ipratropium have not been met. Therefore, we decided that the Plan does not have to pay for oximetry (94761) and albuterol ipratropium (J7620) provided on January 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for the home health aide or certified nurse assistant (S9122) provided from September 11, 2021, to September 17, 2021.  You asked the Plan to reimburse you for the home health services. You say that the services should be paid. The Plan denied your request. The Plan says the provider in this case is not a Medicare certified provider. The Plan also says that payment cannot be made to a provider that is not a certified for Medicare.  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 reimburse you for the home health aide or certified nurse assistant (S9122) provided from September 11, 2021, to September 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (88305, 88312) provided on September 17, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for laboratory services. You say that the doctor's office failed to send in the pre-authorization form for approval. The Plan denied your request. The Plan says This provider is not a network provider with the Plan. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.  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. The record shows that the referring provider was also not a network provider. 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 laboratory services (88305, 88312) provided on September 17, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on October 23, 2021.

You asked the Plan to reimburse you for hearing aids. You say that your condition is severe, and you need to wear hearing aids for your daily use. The Plan denied your request. The Plan says there is no medical emergency, no PCP referral, no pre-authorization, and failure to comply with your Evidence of Coverage.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Specifically, there was no authorization for the hearing aids. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on
October 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve eight surgical placements of implant bodies: endosteal implants (D6010 x8) and two bone grafts at time of implant placement (D6104 x2).  You asked the Plan to pre-approve the endosteal implants and bone grafts. The Plan denied your request. The Plan says these services are 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 pre-approve eight surgical placements of implant bodies: endosteal implants (D6010 x8) and two bone grafts at time of implant placement (D6104 x2).
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 requested IRF care is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the IRF care.

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 on review of the available records, the enrollee with Debility from acute illness, is medically stable. With her comorbid conditions being stable, she does not need Physical Medicine and Rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. No acute or complex rehab nursing needs were noted in the record. At the current functional status, the enrollee needs Physical Therapy and Occupational Therapy, but does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. The enrollee can be safely rehabilitated in a Skilled Nursing Facility. 

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.