Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient hospital services to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve outpatient hospital services. You say that the services are medically necessary. The Plan denied your request. The Plan says according to the enrollee's plan design through the Health Plan, the following limitations and exclusion apply: Members must visit a contracted provider to utilize covered benefits.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve outpatient hospital services to be provided by the requested out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the magnetic resonance (MRI) imaging, brain (including brain stem) (70551).
You asked the Plan to pre-approve the MRI. You say that the enrollee has Parkinsonism and mild cognitive impairment, and it makes sense to image this enrollee. The Plan denied your request. The Plan says based on the provided documentation the enrollee does not meet the guidelines and the requested service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the provided documentation, the changes in symptoms might be related to a new medication and there were no other acute changes noted that would warrant MRI at this time. Trial with change in medication is most appropriate next step. Therefore, the MRI brain will be considered not medically necessary at this time.
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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve the magnetic resonance (MRI) imaging, brain (including brain stem) (70551).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network chiropractor.
You asked the Plan to pre-approve these services. You say that you have been seeing this provider for 20 years. The Plan denied your request. The Plan says the services are available from network providers.
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 referral to an out-of-network chiropractor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Velcro compression stockings.
You asked the Plan to pre-approve Velcro compression stockings. You say that the requested items are a medical necessity for you. The Plan denied your request. The Plan says rules for coverage for the requested items have not been met.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. No medical documentation has been provided in support of this request. Based on this information, we decided that Medicare rules for coverage of Velcro compression stockings have not been met. Therefore, we decided that the Plan does not have to pre-approve Velcro compression stockings.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rocklatan Drop.
You asked the Plan to pre-approve Rocklatan Drop. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered 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 Rocklatan Drop.
Benefits for Rocklatan Drop may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the drug testing (80307 and G0483) provided on June 7, 2021.
You asked the Plan to pay for codes 80307 and G0483. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the medical records do not support the billing of codes 80307 and G0483.
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 80307 is Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service. The definition of code G0483 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT codes 80307 and G0483 are supported in the medical record. Specifically, the laboratory report shows that more than 22 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of codes 80307 and G0483 have been met. Therefore, we decided that the Plan has to pay for the drug testing (80307 and G0483) provided on June 7, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says this level of care does not meet coverage criteria and the skilled nursing facility could meet your needs.
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. You were admitted for
a femur fracture after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you do have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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 IRF admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a battery backup.
You asked the Plan to pre-approve the backup. You say that there are problems with power outages at your home. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. A backup battery cannot be covered, as it is considered duplicative. Therefore, we decided that the Plan does not have to pre-approve a battery backup.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sinus augmentation (D7951) and bone replacement grafts (D4263 x 6).
You asked the Plan to pre-approve the dental services. You say that you need dental implants in order to chew. The Plan denied your request. The Plan says sinus augmentation is not listed as a covered service. The Plan also says bone grafts are not covered services either.
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 sinus augmentation and bone grafts are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve sinus augmentation (D7951) and bone replacement grafts (D4263 x 6).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a CardioMEMS device.
You asked the Plan to pre-approve the requested services. You say that the enrollee needs this device due to his worsening heart failure. The Plan denied your request. The Plan says that there is not enough evidence to prove the use of the device will improve health.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 requested services. Our physician reviewer found that the enrollee has heart failure with depressed ejection fracture. His medical therapy has been limited by chronic hypotension. His right and left heart filling pressures were low on a prior right heart catheterization and his kidney function is compromised, making diuretic and vasodilator therapy difficult to manage. Management of his heart failure with standard medical therapy and relying on symptoms and signs has not been effective in keeping him with minimal symptoms and has resulted in acute hospitalization within the past year. Regular monitoring of filling pressures in this instance would be valuable in trying to titrate the limited guideline medical therapy he has been able to tolerate. There is published expert opinion in the cardiology literature as to the appropriate use of the device, as well as reasonable patient selection criteria, and FDA approved indications all of which are met in this clinical instance. Given the Class III symptoms of congestive heart failure (CHF), which appear very sensitive to volume loading conditions, chronic hypotension limiting the medical regimen, and the failure to prevent acute CHF hospitalization in this enrollee, use of the CardioMEMS device is reasonable in this specific clinical situation. It has clinical data, expert opinion, and approved FDA indications to back up its use. It would therefore not be considered investigational based on these indications, as well as the very specific clinical issues of this enrollee. Therefore, the requested service meets the medical reasonableness and necessity criteria. 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 been met. Therefore, we decided that the Plan has to pre-approve a CardioMEMS device.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 months of skilled nursing visits.
You asked the Plan to pre-approve the skilled nursing visits. You say that you would like reconsideration because you have recently been diagnosed and the requested services are medically necessary. The Plan denied your request. The Plan says you do not have any skilled needs.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 skilled nursing visits. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found you do not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. You have been medically stable without any recent exacerbation of chronic medical problems or hospitalizations. 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 skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 2 months of skilled nursing visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Reblozyl for the enrollee.
You asked the Plan to pre-approve the drug. 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. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found there was no provided evidence of you having myelodysplastic syndrome (MDS) with ring sideroblasts with lower risk or with ring sideroblasts and thrombocytosis and sideroblasts greater or equal to 15%. It appears that based on the provided documentation, you do not have a Food And Drug Administration (FDA)-approved indication for the requested Reblozyl. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Reblozyl for the enrollee.
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 partial lower denture. You say that you never got the dentures that you requested in 2019. The Plan denied your request. The Plan says dentures are covered once per arch, every 60 months. 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 partial lower denture have not been met. Specifically, the frequency limit has been reached.
The record shows that the Plan paid for a partial lower denture that you received on April 10, 2019. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 12 home health skilled nursing visits.
You asked the Plan to pre-approve the continued home health services. You say that it is felt that home health care is needed to maintain the enrollee's condition. The Plan denied your request. The Plan says the enrollee's needs can be met with family and caregivers. There is no requirement for a skilled nurse to provide these services any longer.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 continued home health services. Our reviewer says that the documentation does not show that ongoing home health care is medically necessary. Our physician reviewer found the enrollee has been receiving skilled nursing visits in the home health setting with a right elbow mass being cleaned and dressed. It is noted that 67 visits have been provided thus far. The enrollee does not have documented skilled nursing needs (i.e. injections, complex wound care, new ostomy). It is unclear why the enrollee or caregiver cannot provide the simple care being provided to the enrollee's right elbow. Furthermore, the care is being provided to a mass, not a wound, the prognosis and long-term care needs of which are unclear. The documentation does not show a clear reason that ongoing skilled nursing visits are required. 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 continued home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 12 home health skilled nursing visits
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox (onabotulinumtoxinA) for bladder injection.
You asked the Plan to pre-approve the Botox for injection. You say that this is necessary to treat the enrollee's incontinence. The Plan denied your request. The Plan says this drug is not to be billed by the doctor's office meaning that it cannot be covered by Part B.
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 sent 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 Botox (onabotulinumtoxinA) for bladder injection.
Benefits for the Botox for injection may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower/bath chair with built in commode.
You asked the Plan to pre-approve a shower/bath chair with built in commode. You say that a shower/bath chair with built in commode is medically necessary. The Plan denied your request. The Plan says a shower/bath chair with built in commode is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that shower and bath equipment is not covered because it is not primarily medical in nature. While a shower and bath equipment may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower/bath chair with built in commode
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that you need the compression stocking to keep your feet from swelling. You have an open wound on your left ankle and you wear an Unna boot. The Plan denied your request. The Plan says these dressings are not covered under the surgical dressing benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.