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

We decided that the Plan does not have to pre-approve Euflexxa knee injection services.

You asked the Plan to pre-approve Euflexxa knee injection services. You say that the records provided support that the requested injection services are medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that viscosupplementation is considered not medically reasonable and necessary and will not be covered when a repeat series of injections is initiated prior to six months after completion of the previous course of treatment. 

We looked at the file and Medicare rules. The records show that the enrollee was treated in January 2021 with the first injection. The enrollee received a second injection on April 7, 2021, and a third injection on April 13, 2021. This means that 6 months has not passed since the completion of the previous course of treatment. Based on this information, we decided that Medicare rules for coverage of Euflexxa knee injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa knee injection services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on November 23, 2020.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you received a prescription for Alendronate, which is a new drug for you, and you started having a reaction. You say your heart was racing, and your right fingers and arm were numb, and your stomach was swollen. You say that you called your doctor and she told you to call Advise Nurse on the back of your insurance card and the representative told you to call 911. You say that the paramedics said you were having a reaction to the Alendronate. The Plan denied your request. The Plan says treatment provided by an ambulance without transportation is not covered by your Plan benefits.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 23, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on November 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99255) provided November 12, 2020.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is not eligible for payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99255 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, this service has a status of "I" which means it is invalid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99255) provided November 12, 2020
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 and appropriate for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met, and 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visit and consultation services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the OON office visit and consultation services. You say that the records provided support that the services being requested are medically necessary. The Plan denied your request. The Plan says there are network providers who can evaluate and the treat the enrollee's condition. The Plan says that there is not a network deficiency.
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 OON services. Therefore, we decided that the Plan does not have to pre-approve office visit and consultation services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compressor (E0651) and segmental pneumatic appliance (E0669) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a pneumatic compressor and segmental pneumatic appliance. You say that this item is medically necessary. The Plan denied your request. The Plan says they have in-network providers available to provide this item to the enrollee.

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 pneumatic compressor (E0651) and segmental pneumatic appliance (E0669) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transit system (K0108) for a power wheelchair.
You asked the Plan to pre-approve a transit system. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a transit system (K0108) for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal (D3330).

You asked the Plan to pre-approve the root canal. You say that you would like this service to be approved for coverage because you are in pain. The Plan denied your request. The Plan says this service is not covered.

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 a root canal (D3330).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on February 15, 2021.
You asked the Plan to pay for ambulance services. The Plan denied your request. The Plan says Original Medicare does not cover ambulance services if you are not transported.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 15, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance services provided on
February 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve venography (75822, 75820), intravascular ultrasound
(37252, 37253), ultrasound guidance (76937) and moderate sedation services (99152, 99153) for the enrollee.

You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied
your request. The Plan says that there are other options available to the enrollee that are universally acceptable
among the medical professional community and provide benefit.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. The documentation
does not demonstrate any physical findings or noninvasive imaging suggestive of iliac vein disease. Edema is
noted as being +1 and only in the feet bilaterally. It appears that scheduling of "intravascular ultrasound
diagnosis" was requested prior to performance of the lower extremity venous duplex. Our physician reviewer
found that the enrollee's condition does not meet criteria for coverage of these services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve venography (75822, 75820), intravascular ultrasound (37252, 37253), ultrasound guidance
(76937) and moderate sedation services (99152, 99153) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on February 8, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for specialist services. You say that you had telehealth services with this provider and never had a copayment. You say that this is a financial hardship. The Plan denied your request. The Plan says there are in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The physician who provided these services is not in-network with your new primary care physician. Therefore, we decided that the Plan does not have to pay for specialist services provided on February 8, 2021 by an out-of-network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve coverage for special supplemental benefits.

You asked the Plan to pre-approve coverage for special supplemental benefits. You say that you request an appeal for the denial of special supplemental benefits. The Plan denied your request. The Plan says the enrollee does not meet the criteria established to receive the Special Supplemental Benefits for the Chronically Ill for 2021.

The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of special supplemental benefits have not been met. Specifically, we have confirmed that you do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-approve coverage for special supplemental benefits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.

You asked the Plan to pre-approve hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress (E0260). You say that the enrollee has a need for frequent repositioning to alleviate low back pain and prevent skin breakdown. The Plan denied your request. The Plan says the enrollee does not meet all the requirements.

The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:

1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 

2. Requires attachments which can only be attached to a hospital bed; AND 

3. Requires frequent changes in body position and/or has an immediate need for a change in body position.

We looked at the file and Medicare rules. The medical records show the head of the bed needs to be elevated for the enrollee to breathe comfortably but records do not support immediate need for a change in body position. Based on this information, we decided that Medicare rules for coverage of hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress (E0260) have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Arthrodesis for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee has not failed conservative therapy for at least 6 months.

The Plan must follow Medicare rules. Medicare rules say that minimally-invasive surgical (MIS) fusion of the sacroiliac (SI) joint is considered medically necessary when LCD criteria have been met. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Sacroiliac joint therapy including physical therapy has not been specifically tried. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Arthrodesis for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on November 24, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was billed after the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the services was not filed until March 30, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services provided on November 24, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prostate cushion.
You asked the Plan to pre-approve the cushion. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare does not cover items that are not primarily and customarily used to serve a medical purpose.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a prostate cushion.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral to a cardiologist.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says care can be managed by in-network cardiologists.

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 an out-of-network referral to a cardiologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral above-knee prosthetics to be provided by an out-of-network provider.

You asked the Plan to pre-approve bilateral prosthetics. You say that the requested prosthetics are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not been met.

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 at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve bilateral above-knee prosthetics to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a high frequency chest wall oscillation system.
You asked the Plan to provide a high frequency chest wall oscillation system (E0483). You say that the enrollee wants to try a chest physiotherapy vest. The Plan denied your request. The Plan says there is no supporting documentation indicating the enrollee has a qualifying diagnosis for the requested device.
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall oscillation devise can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to provide a high frequency chest wall oscillation system.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF services.
You asked the Plan to pre-approve continuation of SNF services. You say that the SNF services are medically necessary. The Plan denied your request. The Plan says based on Medicare guidelines, your request for approval of continued SNF care does not meet the requirements for approval.
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 continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found based on review of the medical records provided, you do not meet the CMS coverage criteria for continued stay in an SNF beyond September 17, 2021. Your nursing needs were met. Functionally, there has been no significant progress after nearly a month of the SNF stay. There are no documented daily skilled nursing needs. There is no documentation of your medical conditions, physical therapy and occupational therapy evaluations or progress notes. You do not require daily skilled therapies in an inpatient setting. The documentation does not support the need for continued stay in an SNF beyond September 17, 2021 due to a lack of documented daily nursing needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF services.