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

We decided that the Plan does not have to pre-approve upper eyelid blepharoplasty (15823).
You asked the Plan to pre-approve upper eyelid blepharoplasty. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show that the enrollee has visual complaints.
The Plan follows Medicare rules. Medicare rules say that blepharoplasty may be considered reconstructive when performed to correct visual impairment caused by dermatochalasis, blepharochalasis. blepharoptosis, or brow ptosis. Any procedure(s) involving blepharoplasty and billed to this contractor must be supported by documented patient complaints which justify functional surgery, such as significant interference with vision, difficulty reading, looking through the eyelashes, or seeing the upper eyelid skin. Blepharoplasty is also
covered for repair of anatomical or pathological defects, including those caused by disease (including thyroid dysfunction and cranial nerve palsies), trauma, or tumor-ablative surgery, and relief of eye symptoms associated with blepharospasm. 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 upper eyelid blepharoplasty. Our reviewer says that blepharoplasty is not medically necessary at this time. Our physician reviewer found here is insufficient documentation of functional complaints related to excess upper eyelid tissue or the upper lid position. The documentation does not include difficulty reading due to superior visual field loss, looking through the eyelashes, or seeing upper eyelid skin. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of upper eyelid blepharoplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve upper eyelid blepharoplasty (15823).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by the
requested out-of-network provider.

You asked the Plan to pre-approve physical therapy services to be provided by the requested out-of-network
provider. The Plan denied your request. The Plan says member's needs can be met in-network therefore, going
out of network is not medically necessary. There are 27 in-network providers within a 50-mile radius of the
member's zip code.

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 services at issue in this appeal. 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 physical
therapy services to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Mohs surgery to be provided by a provider at an out of network (OON) location.
You asked the Plan to pre-approve the Mohs surgery at an OON location. You say that you have been seeing the requested provider for a number of years and he has recommended Mohs surgery You say that you have a great deal of trust with this doctor, and he has been highly recommended. You say that, if you go to another dermatology office, it will set you back. The Plan denied your request. The Plan says the requested provider has an in-network location where you can see him. The Plan says that there are also other participating providers who can supply the services needed.
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 services at an OON location. Therefore, we decided that the Plan does not have to pre-approve Mohs surgery to be provided by a provider at an out of network (OON) location.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic casts (D0470), crown repair (D2980), clinical crown lengthening (D4249), and core build-up (D2950) provided by a participating provider.
You asked the Plan to pre-approve diagnostic casts, crown repair, clinical crown lengthening, and core build-up. You say that this dental work was medically necessary. The Plan denied your request. The Plan says these are not covered dental services.
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 diagnostic casts (D0470), crown repair (D2980), clinical crown lengthening (D4249), and core build-up (D2950) provided by a participating provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide 30 additional routine transportation trips.
You asked the Plan to provide additional routine transportation. You say that you have more appointments before the end of the year and rely on this transportation. The Plan denied your request. The Plan says up to 60 routine transportation trips are covered per year. Additional trips are not covered. You have already used all 60 trips covered by this 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. The Plan covers a maximum of 60 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide 30 additional routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care from November 11, 2021, forward.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that you are not ready to be discharged to a lower level of care. You say that you are still experiencing anxiety and depression and do not feel safe to return home. The Plan denied your request. The Plan says the criteria for psychiatric care at the inpatient level were no longer met as of November 11, 2021. The record shows that you were calm and cooperative with a stable mood and no thoughts of self-harm or harming others. Care can be continued in a less restrictive setting.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 continued inpatient psychiatric care. Our reviewer says that the health plan's denial of continued services appears appropriate in this case. Our physician reviewer found that you were admitted to the acute inpatient psychiatric hospitalization on October 25, 2021, with Bipolar Disorder Type II. Based upon review the records provided it was not expected that you would improve in a reasonable period of time beyond the dates in question as you were not showing any dangerousness to self or others, auditory or visual hallucinations and were without aggressive behaviors while not showing any acute threats of safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as you did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. Based upon review the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of November 11, 2021, forward and could have been treated in a lesser restrictive 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 continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care from November 11, 2021, forward.
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 IRF care is medically necessary for this enrollee. The
Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can
safely receive the services they need in 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. 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. 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 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 drug testing coded G0483 provided on November 12, 2020.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on November 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve the home ventilator. You say that a home ventilator is medically necessary. The Plan denied your request. The Plan says coverage criteria were not met for a home ventilator.
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 reviewer says that the service is not medically necessary. Our physician reviewer found according to the records there is insufficient supportive and objective information documented to show the enrollee has a neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure consequent to chronic obstructive pulmonary disease. The documentation in the medical record does not sufficiently support that the ventilator at issue is medically necessary and reasonable for this enrollee. They had not failed other devices such as a BiPAP.
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 a home ventilator.
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 feel IRF care would be more beneficial for you and allow you to return to your prior level of function more effectively. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your ongoing skilled therapy needs are being met in your current facility.
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Ruby 7 HD Electronic Magnifier.
You asked the Plan to pre-approve the Ruby 7 HD Electronic Magnifier. You say that this equipment is medically necessary. The Plan denied your request. The Plan says this equipment is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare does not cover vision aids or vision equipment. Medicare also does not cover self-help devices. While this equipment may be appropriate for your use, this equipment is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve the Ruby 7 HD Electronic Magnifier.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy services coded as B4185, B4193,
B4220 and B4224 provided May 18, 2021 to May 21, 2021.
You asked the Plan to pay for medical nutrition therapy services. You say that the services provided were
medical necessary. Medical records requested have been attached for proper reimbursement. The Plan denied
your request. The Plan says medical nutrition therapy is covered by Medicare only for diabetes, renal disease or
for non-functioning structures that normally permit food to reach the stomach and digestive tract.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services
only for enrollees with renal disease or diabetes.
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy services coded as B4185, B4193, B4220 and B4224 provided May 18, 2021 to May 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is experimental/investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Vertiflex procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Food and Drug Administration states that the requested procedure is contraindicated when the patient has significant scoliosis or osteoporosis. In this case, the record indicates that imaging demonstrates multi-level disease including mild to severe central stenosis, mild to moderate foraminal stenosis, and acute fracture of L4, major scoliosis of undefined amount and osteopenia. The provided record indicates that the enrollee has osteoporosis with associated fracture. The provided record does not state that the enrollee is not indicated for operative treatment at no more than two levels. The elements of the coverage criteria are not satisfied.
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (0037U) provided on November 5, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the out-of-network services were not pre-approved or emergent.
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for lab services (0037U) provided on November 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epoetin Alfa (Procrit). 
 
You asked the Plan to pre-approve Epoetin Alfa (Procrit). You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Epoetin Alfa (Procrit). Our reviewer 
says that the documentation does not support that the requested drug meets step therapy criteria. Our physician 
reviewer found the enrollee anemia in chronic kidney disease. The documentation does not support that the 
enrollee has tried and failed Retacrit. The documentation does not support that the plan's required drug would 
likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet 
criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Epoetin Alfa (Procrit) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Epoetin Alfa (Procrit).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve swimming class. 
 
You asked the Plan to pre-approve swimming class. You say that the swimming class is part of therapy for 
general health maintenance. You say that you need wheelchair transportation to get to the swimming classes. You say that before the pandemic you were receiving transportation to swimming classes. The Plan denied 
your request. The Plan says the services being requested are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits. Medicare rules 
also say that therapy services are only covered when furnished by providers.  
 
The services at issue in this appeal are considered gym benefits. The services at issue in this appeal do not 
show to be furnished by a medical provider or in a medical facility. Therefore, we decided that the Plan does 
not have to pre-approve swimming class.