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

 We decided that the Plan does not have to pay for Als routine disposable supplies (A0398) provided on  March 20, 2021.  You asked the Plan to pay for Als routine disposable supplies. The Plan denied your request. The Plan says procedure A0398RH, which has a status indicator of 'B' on the CMS Physician Relative Value File, is always bundled into payment for other services not specified and no separate payment is made per Medicare.  The Plan must follow Medicare rules. Medicare rules say that payment for items and services is included in the fee schedule payment.   We looked at the file and Medicare rules. Medicare says payment for items and services is included in the fee schedule payment. Therefore, we decided that the Plan does not have to pay for Als routine disposable supplies (A0398) provided on March 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the power wheelchair and accessories to be provided by an OON provider.  You asked the Plan to pre-approve the power wheelchair and accessories. You say that the services are medically necessary. The Plan denied your request. The Plan says the provider is out-of-network.  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. The records provided for review do not show that the services at issue are urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the power wheelchair and accessories to be provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continuation of inpatient psychiatric care from November 29, 2021, forward.  You asked the Plan to pre-approve continued inpatient psychiatric care. You say that these services are medically necessary, and the enrollee is physically unable to care for herself due to depression. The Plan denied your request. The Plan says they have agreed to cover the inpatient admission and services through November 28, 2021, but as of November 29, 2021, psychiatric care at the inpatient level is no longer medically necessary. The enrollee has reached reasonable expectations for improvement and is medically stable at this time.  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 psychiatric care at the inpatient level appears appropriate in this case. Our physician reviewer found that the enrollee was admitted to the acute inpatient psychiatric hospitalization on November 20, 2021 with Major Depressive Disorder, Recurrent Episode, Severe without Psychotic Features. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was compliant with treatment while not showing any acute threats to safety. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in question. Based upon review the records provided for the admission of this patient does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of November 29, 2021, forward.  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 continuation of inpatient psychiatric care from November 29, 2021, forward.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve eight (8) additional PT visits.  You asked the Plan to pre-approve eight (8) additional (PT). You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.  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 eight (8) additional (PT). 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 documentation does not support coverage for additional 8 physical therapy visits which are not medically necessary. The requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition. 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 for physical therapy and occupational therapy, by or under the supervision of a therapist The enrollee does not need a skilled therapist. With a home exercise program, the enrollee can be more mobile on her own. 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 the enrollee's 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 eight (8) additional (PT) have not been met. Therefore, we decided that the Plan does not have to pre-approve eight (8) additional PT visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for DME provided on April 30, 2021.  You asked the Plan to waive the coinsurance for DME. You say that you feel that the charges are too high for the device. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  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 DME and related supplies.   You received DME on April 30, 2021. The total allowed amount is $757.11 and 20% of that is $151.42.   You have been asked to pay the total coinsurance amount of $151.42 for DME. DME falls within the DME and related supplies 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 DME provided on April 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a root canal for a premolar tooth (D3320) for tooth # 12.  You asked the Plan to pre-approve the dental service. You say that the root canal is medically necessary. You also say that you do not want tooth decay. The Plan denied your request. The Plan says root canal is specifically an excluded dental service.  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 root canal not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a root canal for a premolar tooth (D3320) for tooth # 12.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the enrollee needs to be treated in an acute rehab setting for the best chance at a full recovery. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can safely receive the necessary services in an alternate setting.  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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pay for IRF care. You say that the enrollee has a complex medical situation and requires intensive inpatient rehab services to maximize his recovery. A lower level of care is not sufficient for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's care is routine in nature and does not require a team of providers. The necessary services can safely be provided in an alternate setting.  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 pay for 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 pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Monovisc.  You asked the Plan to pre-approve Monovisc. You say that this drug is medically reasonable and necessary. The Plan denied your request. The Plan says step therapy criteria have not been met.  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 Monovisc. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of Durolane, Gelsyn-3, Synvisc/Synvisc-One before they will approve the requested drug. In this case the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Monovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Monovisc.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (G0483, 80307) provided on June 2, 2021.  You asked the Plan to pay for drug testing. You say that this should be covered. The Plan denied your request. The Plan says this was not billed correctly.  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 drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483, 80307) provided on June 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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: 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 need inpatient rehabilitation services. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your 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. 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 pay for a pneumatic compression device (E0673, E0675).  You asked the Plan to pay for a pneumatic compression device. You say that this should be paid for. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Apokyn 10mg/ml injection.  You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says drug coverage is limited to only the drugs covered under the Part B medical benefit.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Apokyn 10mg/ml injection.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to provide ten (10) additional routine transportation trips.  You asked the Plan to provide additional routine transportation. You say that these services are necessary for you to get to your appointments. The Plan denied your request. The Plan says a maximum of 24 routine transportation trips are covered per year. Additional trips are not a covered 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 24 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 ten (10) additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network practitioner services provided to the enrollee on August 3, 2021.   You asked the Plan to pay for these services. You say that this claim should be paid. 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 must 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 practitioner services provided to the enrollee on August 3, 2021.