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 SNF services. The Plan denied your request. The Plan says you are receiving adequate and necessary care at the intensive rehabilitation facility.  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 services. Our physician reviewer found that you were admitted to an acute inpatient rehabilitation facility with right sided weakness, dysarthria, and dysphagia after a stroke. You have been working with physical, occupational and speech therapy. You are reported to be non-ambulatory and requiring a wheelchair for mobility. You require an assist device for transfers, and moderate to maximum assistance for activities of daily living. The notes indicate she continues to tolerate and benefit form treatment with a goal to return home. You do not require the services on an inpatient basis, only in a skilled nursing facility setting. Continued care in the acute inpatient rehabilitation facility is appropriate until you are stable to transfer back home or to another community-based environment.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to provide coverage for additional routine transportation trips.  You asked the Plan to provide coverage for additional routine transportation trips.. You say that you have an appointment in December, and you have no other means of transportation. The Plan denied your request. The Plan says you have exhausted the maximum benefit of 12 one-way trips per year.  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 12 one-way trips per year.    We looked at your request, the records in the case file, and the rules. The records show that you have used 12 one-way transportation trips this year. 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 coverage for additional routine transportation trips.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided on May 29, 2021.  You asked the Plan to pay for the transportation services. You say that the claim was denied incorrectly. You also say that the transport provided was between hospitals. The Plan denied your request. The Plan says a physician certification statement (PCS) was not submitted. The Plan also says that documented attempts to obtain one were not submitted either.  The Plan must follow Medicare rules. Medicare rules say that Medicare covers medically necessary non-emergency ambulance services that are either unscheduled or that are scheduled on a non-repetitive basis for a resident of a facility who is under the care of a physician if the ambulance provider or supplier obtains a physician certification statement within 48 hours after the transport.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transportation services have not been met. Specifically, the file does not show that a PCS was obtain, nor are there documented attempts to obtain one. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided on May 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.  You asked the Plan to pre-approve these services. You say that the member has tried non-operative treatment that has not worked. The Plan denied your request. The Plan says that there is little evidence in the medical literature to suggest that this is an appropriate procedure for the enrollee's back pain.  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 intracept procedure is experimental for low back pain. More research is needed to show safety and efficacy. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 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 the Intracept procedure for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (87631) provided on August 3, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services (87631) provided on August 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to provide coverage for ten (10) additional routine transportation trips (A0120).  You asked the Plan to provide coverage for additional routine transportation trips. You say that you have several upcoming appointments and need additional transportation. The Plan denied your request. The Plan says you have exhausted the maximum benefit of 48 one-way trips per year.  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 48 one-way trips per year.   We looked at your request, the records in the case file, and the rules. The records show that you have used 48 one-way transportation trips this year. 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 coverage for ten (10) additional routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit and the laboratory services rendered by the out-of-network (OON) provider on March 18, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  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 services at issue in this appeal.  The Plan did not pre-approve the services 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 the office visit and the laboratory services rendered by the out-of-network (OON) provider on March 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a transfer from an in-network inpatient psychiatric facility to an out-of-network inpatient psychiatric facility.  You asked the Plan to pre-approve transfer to an out-of-network facility. You say that the enrollee requires ongoing inpatient psychiatric care and has been ordered to continue services at a different facility. The Plan denied your request. The Plan says the facility requested for transfer in this case is not part of the Plan's network. The enrollee was already approved for ongoing care in the in-network facility, where she was receiving medically necessary services. There is no indication that the out-of-network facility is able to provide services that are necessary for the enrollee, but that she is unable to receive in the in-network facility. The enrollee's care can be provided in-network, and therefore the out-of-network services requested are denied.  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 transfer from an in-network inpatient psychiatric facility to an out-of-network inpatient psychiatric facility.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the hypoglossal nerve stimulator.  You asked the Plan to pre-approve the hypoglossal nerve stimulator. You say that this request is medically reasonable and 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 a qualified polysomnography must have been performed before the services are rendered.   We looked at the file and Medicare rules. In this case, the home sleep study that you have had does not qualify as the required polysomnography. Based on this information, we decided that Medicare rules for coverage of the hypoglossal nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve the hypoglossal nerve stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for the office visits (99211) provided on  June 10, 2021 and July 1, 2021.  You asked the Plan to waive the deductible. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the deductible has been applied correctly to the services provided.  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 a deductible does apply for Medicare-covered acupuncture services rendered by an out-of-network provider. Your out-of-network Point of Service (POS) deductible is $1,500. This is the amount you have to pay out-of-pocket before the Plan will pay their share for your covered out-of-network (POS) medical services. Until you have paid the out-of-network deductible amount, you must pay the full cost of your covered out-of-network services. Once you have paid your out-of-network deductible, the Plan will begin to pay their share of the costs for covered out-of-network medical services.   You have been asked to pay $160 for the Medicare-covered office visits for acupuncture services rendered by an out-of-network provider. This is the Plan's allowed amount for the services provided. You are responsible to pay this amount as you had not previously met the yearly deductible of $1,500. 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 deductible for the office visits (99211) provided on June 10, 2021 and July 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for a radiofrequency ablation of the right genicular nerves (64624) provided on February 10, 2021.  You asked the Plan to pay for a radiofrequency ablation of the right genicular nerves. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the procedure at issue 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 pay for a radiofrequency ablation of the right genicular nerves. Our reviewer says that the services at issue are not considered medically reasonable and necessary in this case. Our physician reviewer found that the services at issue are an experimental/investigational procedure that is the subject of ongoing clinical trials.  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 radiofrequency ablation of the right genicular nerves have not been met. Therefore, we decided that the Plan does not have to pay for a radiofrequency ablation of the right genicular nerves (64624) provided on February 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services (procedure code 73564) provided to the enrollee on May 24, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this needs a modifier 26.  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 73564 is "Radiologic examination, knee; complete, 4 or more views."  We asked our coder 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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the documentation submitted was reviewed, and it does not meet the criteria. For services provided with a place of service of 22, modifier 26 should be appended.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for imaging services (procedure code 73564) provided to the enrollee on May 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Bexsero.  You asked the Plan to pre-approve Bexsero. You say that this drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 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 Bexsero.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a second opinion to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve OON services. You say that you do not want your esophagus removed. The Plan denied your request. The Plan says there are available providers in the 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 oncology services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve a second opinion to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the nutria-pharmaceutical injections to be used with Sanexas device treatments.  You asked the Plan to pre-approve the nutria-pharmaceutical injections. You say that it is felt that the use of the Sanexas device helps to relieve symptoms of neuropathy by regenerating nerve cells. The Plan denied your request. The Plan says the use of vitamin injections with electrical stimulation has not been shown to be effective at nerve regeneration or reduction in neuropathy symptoms in the peer-reviewed literature.  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 the nutria-pharmaceutical injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a male with hereditary and idiopathic neuropathy and foot drop. The records shows that the enrollee's treating neurologist is skeptical regarding the efficacy of the requested treatment. The clinical documentation does not support that the requested treatments are shown to be clinically effective or that they are medically reasonable and necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections have not been met. Therefore, we decided that the Plan does not have to pre-approve the nutria-pharmaceutical injections to be used with Sanexas device treatments.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, K0108, K0108).  You asked the Plan to pre-approve the additional accessories. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.  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 the additional accessories. Our reviewer says that the requested additional accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found the calf pads (K0108) are not covered as they are classified as replacement items and cannot approved with the initial issue. The wedge (K0108) is not allowed as E2608 covers all allowed seat back and cushion components. The electrical connection (E2311) does not meet criteria as the provided records document that the enrollee has 4+/5 to 5/5 upper extremity strength and he is supervision or set-up assist for grooming, bathing and dressing. These examination findings indicate the enrollee has adequate upper extremity strength and function to operate the wheelchair's power options with their own switches.   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 additional accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, K0108, K0108).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Entyvio for the enrollee.  You asked the Plan to pre-approve Entyvio. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the member has not tried and failed Stelara.  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 Entyvio. Our reviewer says that Entyvio is not medically reasonable and necessary for the enrollee. The patient has not tried and failed Remicade OR Inflectra; AND Stelara. 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. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Entyvio.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Linzess.  You asked the Plan to pre-approve Linzess. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.  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 Linzess.     Benefits for Linzess may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.