Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a partial lower denture (D5214).  You asked the Plan to pre-approve the dental item. You say that you need the partial denture. The Plan denied your request. The Plan says partial lower denture is not listed as a covered 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 partial lower denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the hand finger orthosis (L3913) to be provided by an out-of-network (OON) provider.  

You asked the Plan to pre-approve the hand finger orthosis. You say that the item should be covered. The Plan denied your request. The Plan says there are providers in-network that you can obtain this item from. 

 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 hand finger orthosis (L3913) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network (OON) provider.  

You asked the Plan to pre-approve the office visit. You say that you are in a lot of back pain and would like to see the out-of-network provider for treatment options. 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. Therefore, we decided that the Plan does not have to pre-approve the office visit 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 the enteral nutrition (B4150).  

You asked the Plan to pre-approve the enteral nutrition. You say that you need this item. The Plan denied your request. The Plan says you do not meet the requirements for this item.  

The Plan must follow Medicare rules. Medicare rules say that the enteral nutrition is covered for beneficiaries who require tube feedings to provide sufficient nutrients to maintain weight and strength commensurate with the beneficiary's overall health status.  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the enteral nutrition have not been met. Therefore, we decided that the Plan does not have to pre-approve the enteral nutrition (B4150).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely be received in a different setting.  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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable oxygen concentrator to be provided by an out-of-network (OON) provider.  

You asked the Plan to pre-approve a portable oxygen concentrator. You say that the item should be covered. The Plan denied your request. The Plan says there are providers in-network that can provide this item.  

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 portable oxygen concentrator to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an additional sacroiliac joint injection.  You asked the Plan to pre-approve the requested services. You say that you do not want to be on pain medications. The Plan denied your request. The Plan says further injections are not medically necessary until the results of the first injection are known.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   The file shows that 2 sacroiliac joint injections were requested. The Plan has agreed to pre-approve 1 injection. 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 additional services. Our physician reviewer found that in this case, you have low back pain. The record indicates that a first injection was approved and planned late December 2021. The record does not include documentation of the results of the first injection. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules.    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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional sacroiliac joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99214) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve an office visit. You say that this care is medically necessary. The Plan denied your request. The Plan says there are in-network providers that are available to treat the enrollee's condition.

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 office visit (99214) 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 group 3 power wheelchair (K0856).

You asked the Plan to pre-approve a group 3 power wheelchair. You say that this would benefit the enrollee. The Plan denied your request. The Plan says the requirements for coverage have not been met.

The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 

1. A neurological condition; 

2. Myopathy; or 

3. Congenital skeletal deformity. 

The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0856).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met in an alternate level of care.  

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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for observation discharge day management services (99217) provided on August 16, 2021.  

You asked the Plan to pay for the observation discharge day management services. You say that you would like reconsideration because this member was seen by different providers on the same date of service.  The Plan denied your request. The Plan says a qualifying initial or subsequent observation care service was notfound in the member's claims history.  

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 99217 is not supported in the record. Specifically, the record does not include any documentation that initial observation or subsequent observation codes were billed by this provider. Based on this information, we decided that Medicare rules for coverage of the observation discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for observation discharge day management services (99217) provided on August 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a complete upper denture (D5110), and a complete lower denture (D5120).  You asked the Plan to pre-approve the dental items. You say that after several adjustments your current dentures still do not fit properly. You say that your current dentures were not well made. You say that they are a hazard to your health. You also say that you need a new set of dentures. The Plan denied your request. The Plan says dentures are covered once every 5 calendar years. The Plan also says that the frequency limit has been reached.  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.   We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental items have not been met. Specifically, the frequency limit has been reached. The record shows that the Plan paid for dentures that you received on December 8, 2020. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110), and a complete lower denture (D5120).
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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  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 the enrollee appears to be unstable at this time and requires additional short-term additional acute care services to further stabilize that can be safely administered at the current facility for the time being. There are no services at the LTACH that the enrollee requires that are not already available at the current 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 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for genetic testing provided to the enrollee on May 21, 2021.  

You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare coverage criteria are not met.  

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. This testing was requested solely for screening purposes. There is no indication in the records provided that the result of this testing would be used to make specific treatment decisions for the enrollee. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve wound care visits to be provided by an out-of-network (OON) provider.  

You asked the Plan to pre-approve wound care visits. You say that the requested provider is close to your home. The Plan denied your request. The Plan says the requested services are available in-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. Therefore, we decided that the Plan does not have to pre-approve wound care visits to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Syvnisc-One.  You asked the Plan to pre-approve Syvnisc-One. You say that the requested drug is medically reasonable and necessary for your condition. 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 Syvnisc-One. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found  In this case, the record indicates that the enrollee has osteoarthritis of the knee.  The requested medication is a new start.  The enrollee has provided a statement that she tried and failed Durolane but has not trialed Euflexxa.  The record does not contain any other records. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Syvnisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Syvnisc-One.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a lumbar/sacral facet injection.  

You asked the Plan to pre-approve a lumbar/sacral facet injection. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  

The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet specific criteria.  

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 lumbar/sacral facet injection. Our reviewer says that the services are not medically necessary. Our physician reviewer found the record does not document that you have had pain for a minimum of three months. The record does not indicate the results of the physical therapy treatment you were receiving. The elements of the coverage criteria are not satisfied. The requested service is not recommended.  

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 lumbar/sacral facet injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar/sacral facet injection.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for genetic testing provided to the enrollee on May 12, 2020 and billed under codes 87496, 87498, 87631, 87798, 87486, 87541, 87581, and 87640.  

You asked the Plan to pay for lab services provided to the enrollee. You say that this claim should be paid. The Plan denied your request. The Plan says while code U0004 will be paid, codes 87496, 87498, 87631, 87798, 87486, 87541, 87581, and 87640 remain denied because the place of service code listed on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The claim form indicates the laboratory specimen was obtained in a laboratory, place of service code 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in a Health and Rehab center or place of service code 31. Also, the laboratory results submitted indicate the specimen was collected on May 12, 2020 and received by the lab on May 13, 2020. The Plan also noted the enrollee lives in Florida and the billing laboratory is located in Texas. Therefore, the billed code cannot be verified. The Plan notes multiple attempts were made to obtain additional information from the provider.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the claim was not submitted with an appropriate place of service coded based on the records provided. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on May 12, 2020 and billed under codes 87496, 87498, 87631, 87798, 87486, 87541, 87581, and 87640.