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 the SNF services. You say that you have not improved and feel you need the 
requested rehabilitation in order to regain your strength, endurance, and balance in order to go home alone. The 
Plan denied your request. The Plan says the records do not show that the enrollee needs skilled services on a 
daily basis. The Plan says that the services required can be safely received at a different setting.

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 services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of the enrollee's 
condition. The enrollee's care needs are custodial and, as a practical matter, can be provided 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 the 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network chiropractic services provided to the enrollee from July 21, 2020, to August 27, 2020.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 out of network chiropractic services provided to the enrollee from July 21, 2020, to August 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Synvisc syringe (J7325).

You asked the Plan to pre-approve Synvisc. You say that you tried Synvisc in July 2019. You say that you had great relief and improved function up until recently. You also say that you tried Orthovisc in May 2019. The Plan denied your request. The Plan says you not tried and failed the required drug, Monovisc.

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 Synvisc. Our reviewer says that Synvisc is not medically necessary. Our physician reviewer found the provided documentation shows you have tried Orthovisc, however, you have not trialed viscosupplemental treatment with Monovisc. Step therapy, as outlined by the Plan, requires that both of these be trialed first. The reviewer found that the documentation does not outline contraindications or reasons Monovisc was not considered or that the Plan's required drugs would likely be less effective and/or likely have adverse effects for you. Therefore, without the support of the documentation, Synvisc is not approved as step criteria have not been met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Specifically, the file does not show that you have tried and failed the preferred drug, Monovisc. Therefore, we decided that the Plan does not have to pre-approve a Synvisc syringe (J7325).
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 for the enrollee.

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 the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of 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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for nonoperative management of a lumbar compression fracture after a fall. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the respiratory assist device you rented from February 24, 2021, to June 4, 2021.
You asked the Plan to waive the coinsurance for the respiratory assist device. You say that you have never been charged monthly before. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that this item is a rental item, so you are appropriately assessed coinsurance on a monthly basis.
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 20% coinsurance for durable medical equipment.
You have been asked to pay 20% coinsurance for the respiratory assist device. The respiratory assist device falls within the durable medical equipment 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 coinsurance for the respiratory assist device you rented from February 24, 2021, to June 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided by a non-participating provider on November 27, 2020, to December 1, 2020.
You asked the Plan to pay for inpatient hospital care. You say that G93.41 is a valid diagnosis as the condition is supported by provider documentation and evidence of worsening confusion, and mental status deficits of attention and concentration. The Plan denied your request. The Plan says G93.41 - metabolic encephalopathy, could not be validated as a secondary diagnosis.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with secondary diagnosis code, G93.41 - metabolic encephalopathy. 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 inpatient hospital care. Our reviewer says that the record indicates that upon admission, the enrollee was afebrile with a normal white blood cell count. Our physician reviewer found the record does not establish metabolic encephalopathy but rather supports worsening dementia. The enrollee did not have evidence of renal or pulmonary dysfunction. The elements of the coverage rules were not satisfied; therefore, the requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided by a non-participating provider on November 27, 2020, to December 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neurostimulator service.

You asked the Plan to pre-approve neurostimulator service. 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 follows Medicare rules. Medicare rules say that dorsal column stimulators may be covered as therapies for the relief of chronic intractable pain under specific circumstances. 

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 neurostimulator service. Our reviewer says that the services are not medically necessary. Our physician reviewer found the provided record does not indicate that the spinal cord stimulator is being used as a treatment of last resort in an enrollee with chronic intractable pain. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neurostimulator service have not been met. Therefore, we decided that the Plan does not have to pre-approve neurostimulator service.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth debridement (D4355) provided on May 20, 2021.
You asked the Plan to pay for full mouth debridement. You say that you were unable to use your dental benefits for a while due to medical reasons, so this longer cleaning was necessary. The Plan denied your request. The Plan says full mouth debridement is not covered by your dental benefit.
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 full mouth debridement (D4355) provided on May 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on May 19, 2021.

You asked the Plan to pay for the eye refraction. You say that this service was medically necessary due to sudden changes in vision and should be covered under your medical benefits. The Plan denied your request. The Plan says eye refractions are not a covered service under Medicare. The Plan's supplemental benefit will only cover eye refractions when they are received from a routine vision provider as part of an annual eye exam. The provider in question is not part of the routine vision network.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are provided as part of a routine vision exam performed by a provider in the Plan's specified routine vision network. 

We looked at the file and the Plan's rules. The eye refraction in this case was not performed by a provider in the specified network and was provided for medical purposes. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on May 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87541, 87581,
87640, 87798) provided on July 13, 2020.
You asked the Plan to pay for laboratory services. You say that this should be covered as in-network. The Plan
denied your request. The Plan says this was not billed with the correct place of service. The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS).
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent
laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we
decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that
the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87541, 87581, 87640, 87798)
provided on July 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) scan rendered on 
March 12, 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 claim was not billed with a valid primary diagnosis code. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 

We looked at the file and Medicare rules. The file shows that the services were not billed with a valid primary 
diagnosis code. 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 pay for the positron emission tomography 
(PET) scan rendered on March 12, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the needle electromyography rendered on July 28, 2020.
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 procedure code 95861 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 95861 is needle electromyography; 2 extremities with or without related paraspinal areas.
We find that CPT code 95861 is not supported in the medical record. Specifically, there is no documentation of needle electromyography of two extremities with or without related paraspinal areas. 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 pay for the needle electromyography rendered on July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tetanus booster provided on July 1, 2021.
You asked the Plan to pay for the Tetanus booster. You say that you would like reconsideration because your
physician recommended you get this booster. The Plan denied your request. The Plan says the vaccine is a Part
D drug that is not covered in a provider setting unless it is given due to an injury. In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tetanus booster.
The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the Tetanus
booster. Therefore, we decided that the Plan does not have to pay for the Tetanus booster provided on July 1,
2021.
Benefits for the Tetanus booster 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you did not require any skilled nursing or rehabilitation services on a daily basis at an inpatient level of care. You were not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living (ADLs). You did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, you did not require any skilled services on an inpatient basis, at a SNF level of care at the time of discharge from the rehabilitation 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Creon to be dispensed by a pharmacy.
You asked the Plan to pre-approve Creon. You say that the enrollee needs this medication for his condition.
The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this
drug is to be dispensed by a pharmacy which is a Medicare Part D covered event and not a Medicare Part B
benefit.
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 Creon to be dispensed by a pharmacy.
Benefits for Creon 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 pre-approve a facet joint injection.
You asked the Plan to pre-approve a facet joint injection. 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 follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are allowed per session per spine region. 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 a facet joint injection. Our reviewer says that the services are not medically necessary. Our physician reviewer found the information submitted fails to meet medical necessity criteria for cervical region facet joint radiofrequency ablations (64633, 64634 (2 units)). The requested radiofrequency ablations have been denied as the request is for three levels (right sided cervical levels C5, C6, C7) when only two levels are allowed. Additionally, the imaging provided for review is not current as it from August 27, 2017. Lastly, it has been approximately four years since the last medial branch block and per the Local Coverage Determination they must have been completed no more than two years ago. The review has determined that the enrollee does not meet the criteria for the requested procedure.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a facet joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a facet joint injection.