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

We decided that the Plan does not have to pay for the lab services provided on April 13, 2021.
You asked the Plan to pay for the lab services. You say that you would like reconsideration because you believe lab services should be covered. The Plan denied your request. The Plan says the lab services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services in the medical record, is required for Medicare-covered laboratory services. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, the record indicates that you did not receive a physician order for the rendered tests.
Additionally, there are no medical records to verify why this testing was medically necessary. Therefore, we decided that the Plan does not have to pay for the lab services provided on April 13, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient therapy services (90832) provided February 18, 2021.
You asked the Plan to pay for the outpatient therapy services. You say that this service was medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that for outpatient mental health services to be covered, the provider must consult with the enrollee's primary or attending physician. We looked at the file and Medicare rules. There is no record of any attempt to consult with the enrollee's primary physician. Based on this information, we decided that Medicare rules for coverage of the outpatient therapy services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient therapy services (90832) provided February 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this device is 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 therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
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 an intensive, complex, multidisciplinary approach to daily 
therapy. Your rehab needs can be safely met in an alternate and low intensity setting such as in-home with 
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 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 long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically
necessary for this enrollee. The Plan denied your request. The Plan says the enrollee is receiving appropriate
inpatient care in the current facility. Transfer to an LTACH would not provide a clinical advantage and is
therefore not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation provided indicating medical necessity for admission to a
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not
require services at the LTACH that are not available at the acute care hospital where they are currently
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at
the health care setting being offered by the health plan.
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the follow-up visits to be provided by out-of-network providers.
You asked the Plan to pre-approve the out-of-network follow-up visits. You say that the appointment you have is for a post-operation follow-up from a surgery done on August 17, 2021. You state it is a telemed appointment and you need to follow up. The Plan denied your request. The Plan says this service could be provided by an in-network Health Plan provider. The Plan states they approved this surgery to the out-of-network provider due to the Emergency Declaration. The Plan stated once this expires on October 18, 2021, you will need to have your provider refer you to a network provider for continued in-network coverage, or re-submit a new request for out-of-network coverage to be re-reviewed.
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 the follow-up visits to be provided by out-of-network providers.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.

You asked the Plan to pre-approve Durolane. The Plan denied your request. The Plan says you have not tried and failed Orthovisc and Monovisc.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Durolane. Our physician reviewer found that you have osteoarthritis of the knees. The Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. In this case, you have not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective or likely have adverse effects.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870).

You asked the Plan to pre-approve the surgery. You say that the posterior interspinous decompression spacer procedure is to treat lumbar spinal stenosis with neurogenic claudication. The Plan denied your request. The Plan says the services are considered experimental and 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 the surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy. 

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 surgery have not been met.

Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870).
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 the complexity of your medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Care at the skilled nursing facility level appears to be appropriate in this case. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sinus augmentation with bone or bone substitutes via a lateral open approach (D7951), overdenture - complete mandibular (D5865), overdenture - complete maxillary (D5863), and bone replacement graft for ridge preservation - per site (D7953).
You asked the Plan to pre-approve sinus augmentation, complete lower and upper overdentures, and bone replacement graft. You say that you would like the services covered. The Plan denied your request. The Plan says these services are not covered under your benefits.
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 sinus
augmentation with bone or bone substitutes via a lateral open approach (D7951), overdenture - complete mandibular (D5865), overdenture - complete maxillary (D5863), and bone replacement graft for ridge preservation - per site (D7953).
Please note that the Plan has indicated that your dentist will re-submit surgical stent (D5982) and custom fabricated abutment - includes placement (D6057) to the dental vendor and therefore these services have not been reviewed in this appeal.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network pain management specialist.
You asked the Plan to pre-approve these services. You say that you have seen this provider in the past. The Plan denied your request. The Plan says the services are available from network providers.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is not providing these services and is not making arrangements to provide these services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network pain management specialist.
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 service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
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 the enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, 
there is no documented need for a intensive, multi-disciplinary rehabilitation program. 
 
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. Specifically, medically necessary services can be 
obtained at a lower level of care. This means admission into an IRF is not medically necessary ore reasonable. 
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 a home ventilator.
You asked the Plan to pre-approve ventilator. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because this request is for a home ventilator in average volume-assured pressure support (AVAPS) mode that could be delivered by a bilevel positive airway pressure (BiPAP) device instead.
The Plan follows Medicare rules. Medicare rules state that a ventilator is not covered when used to provide bilevel positive airway pressure therapy, and the determination to use a ventilator versus a bilevel positive airway pressure device is made based upon the specifics of the enrollee's medical condition. 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 ventilator. Our reviewer says that you do not meet the Medicare criteria for a ventilator. Our physician reviewer found the record indicates that you have chronic respiratory failure from obstructive sleep apnea. This condition is not an approved indication for coverage. Notwithstanding this fact, the Plan has indicated that they would consider coverage of an appropriate device. You have responded to treatment with bilevel positive airway pressure (BiPAP) with average volume-
assure pressure support (AVAPS) settings. The documentation does not contain sufficient detailed information to justify the treatment selected. You could be treated with a BiPAP machine with AVAPS capability, which the Plan has indicated is covered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 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 an intensive, complex, multidisciplinary approach to daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day, at least 5 days per week with frequent physician oversight and an interdisciplinary approach to rehabilitation care. Your rehab needs can be safely met in an alternate and low intensity setting such as a skilled nursing facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 a high frequency chest wall oscillation device (HFCWOD).
You asked the Plan to pre-approve a HFCWOD. You say that these services are medically necessary. The Plan denied your request. The Plan says that your records don't show you meet criteria for coverage.
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. 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 HFCWOD. Our reviewer says that a HFCWOD is not medically reasonable and necessary in this case. The record indicates that you have moderate persistent asthma and allergic rhinitis not controlled with medication.
The provided records do not indicate that you have bronchiectasis. Our physician reviewer found that your condition does not meet Medicare criteria for a HFCWOD. 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 HFCWOD have not been met. Therefore, we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound interpretation provided on May 25,
2021, billed with code 76700-26.
You asked the Plan to pay for the ultrasound interpretation. You say that the enrollee received multiple exams
on this date of service so this should be denied as duplicate. The Plan denied your request. The Plan says the
Column 2 code was not billed with an appropriate modifier.
The Plan must follow Medicare rules. Medicare rules say that when an NCCI edit exists for a code pair, only
the Column 1 code is payable unless a clinically appropriate modifier is used.
In this case, code 76700 is a Column 2 code in relation to 93976 which was paid on this same claim. No NCCI
modifier was used to justify bypassing this edit. Therefore, we decided that the Plan does not have to pay for
the abdominal ultrasound interpretation provided on May 25, 2021, billed with code 76700-26.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the vascular surgery consultation to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the vascular surgery consultation. You say that the service is 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 service at issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve a vascular surgery consultation to be provided by an out-of-network (OON) provider.