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

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital for spinal fusion after a fall. His medical problems are stable and he has no complex nursing or rehabilitation needs. He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While he has 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 the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Injectafer.  You asked the Plan to pre-approve Injectafer. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no indication the preferred drugs would likely be less effective, and/or cause adverse effects for you.  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 Injectafer. Our reviewer says that Injectafer is not medically reasonable and necessary. There is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for you. Our physician reviewer found that your condition does not meet step therapy criteria for Injectafer.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the portable oxygen concentrator (E1392).  You asked the Plan to pre-approve the portable oxygen concentrator. You say that the item is medically necessary. The Plan denied your request. The Plan says there is no documentation of you being evaluated by Respirator Therapy for any oxygen needs and you have yet to try standard oxygen equipment.  The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.    To qualify for home oxygen, the patient must meet one of the following blood gas levels:  1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;  2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep;   3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise;  4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia.  For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage.  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 portable oxygen concentrator. Our reviewer says that the item is not medically necessary. Our physician reviewer found there is no demonstration that supplemental oxygen corrects the hypoxemia and in order for a POC to be covered, the SpO2 must be able to be maintained at least 91% on a flow rate of 1 to 4 L/min using an oxygen conserving device.  Also, there is no demonstration that portable refillable tanks would not meet your needs.  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 portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve the portable oxygen concentrator (E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).  You asked the Plan to pre-approve a portable oxygen concentrator. You say that your current tank is too hard to walk with. The Plan denied your request. The Plan says you have already been provided the most appropriate equipment to meet your needs; duplicates are not covered.  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.  The file shows that you have standard oxygen tank. Standard oxygen tanks serve the same purpose as the portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from March 17, 2021, through April 15, 2021.  You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says SNF services are not medically necessary.  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 pay for SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the documentation provided, the enrollee did not qualify for SNF coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition.  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 pay for SNF services provided from March 17, 2021, through April 15, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that the enrollee requires additional time in a SNF. The Plan denied your request. The Plan says that the enrollee has reached the benefit limit for these services.

The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. 

The file shows that the enrollee received 100 days of SNF care during the benefit period from August 5, 2021 through August 6, 2021, August 9, 2021 through October 17, 2021, and October 20, 2021 through November 18, 2021. The Plan has covered 100 days of SNF care.

Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rytary 245mg caplet 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 the enrollee does not have pharmacy/drug benefits administered by the plan.

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 Rytary 245mg caplet for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the shoe inserts (L3020).

You asked the Plan to pre-approve foot orthotics. You say that the item is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve the shoe inserts (L3020).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2752) provided on tooth #31 on July 26, 2021.

You asked the Plan to pay for the crown. You say that the crown was provided because a sizeable portion of your tooth broke off, and it was uncomfortable. The Plan denied your request. The Plan says tooth #31 does not appear to have significant breakdown. The Plan also says that the documentation provided does not demonstrate that there is pathologic destruction to the tooth by caries or trauma involving 4 or more surfaces and at least two cusps.

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. The Plan covers the crown when the services are medically necessary and reasonable.

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 the crown. Our reviewer says that there would be no necessity for the requested procedure under the Plan. Our physician reviewer found the tooth #31 had an existing one surface restoration, and a recent cusp fracture. Under the Plan criteria, in order to qualify for a crown restoration there must be more tooth damage than exists on tooth #31. Our reviewer also found that given there would be at most three involved surfaces (occlusal, mesial and lingual) and one cusp, the criteria for coverage under the Plan would not be met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pay for the crown (D2752) provided on tooth #31 on July 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Regener-Eye drops purchased on March 24, 2021.
You asked the Plan to pay for self-administered non-FDA approved eye drops. You say that you purchased
these eye drops through your doctor's office and they should be covered. The Plan denied your request. The
Plan says these are self-administered eye drops that are not covered under Medicare. We overturned the
Plans denial because they were recommended by your physician. The Plan requested a reopen and stated that
you were made aware by your physician that they were not covered by insurance but chose to purchase them
anyway.
The Plan is correct in this case. The Plan must follow Medicare rules. Self-administered non-FDA approved
eye drops are not covered whether they are recommended by a physician or nurse practitioner or optometrist.
The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered
eye drops purchased in this case are not among the types which are covered by Medicare Part B. Therefore, we
decided that the Plan does not have to pay for Regener-Eye drops purchased on March 24, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to hold you harmless for the computerized topography (CT) scan of the cornea (92025) provided on August 11, 2021.  You asked the Plan to hold you harmless for the corneal CT scan. You say that this was a necessary medical scan which was done in preparation for your upcoming cataract surgery. You also say this service was performed by a provider in the same location as your regular medical eye doctor. The Plan denied your request. The Plan says that this service was performed by a provider outside of the Plan's routine vision network. Only routine vision services provided within this network may be covered.  Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. The rules also say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan denied this service on the basis that it was provided outside of the routine vision care network, but by your attestation, this was a medical scan provided to prepare you for a cataract surgery. Cataract surgery falls under the medical benefit, and a corneal CT scan is not generally/necessarily provided for routine purposes. No medical records were requested or provided to verify if this service is medical or routine in nature. We asked the Plan for additional clarification regarding whether this provider is part of your medical network. We were unable to find definitive information showing that this provider is not part of this network, and the Plan did not respond to our request for information or provide further clarification. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request.  You say you were referred for this corneal CT scan by your usual eye doctor who works in the same location. The file does not show that the Plan provided notice that the corneal CT scan would not be covered. Under Medicare rules, this means the corneal CT scan is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the computerized topography (CT) scan of the cornea (92025) provided on August 11, 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 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 enrollee does not require IRF level of therapies consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from continued physical therapy, and occupational therapy, her rehab needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility or in home with therapies.  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 the Volara system.  You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says there is no data to support the effectiveness of this device.  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 the system. Our reviewer says that the requested system is not medically reasonable or necessary. Our physician reviewer found you have cystic fibrosis, pulmonary disease, cirrhosis of the liver, diabetes, and lupus. The Volara system combines intrapulmonary oscillation, positive end-expiratory pressure, and nebulization. There is inadequate evidence that this system is beneficial in the home setting in any lung disease. You already have a nebulizer, and that treatment would be duplicated. You do not have atelectasis.  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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve the Volara system.
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. You say that these services are medically necessary. The Plan denied your request. The Plan says that you have no daily skilled nurse or therapist needs.  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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for orthopedic surgery (procedure code 27130) provided to the enrollee on August 8, 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 a corrected claim has not been received with the missing modifier.  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 27130 is "Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft."  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 CPT 27130 requires an appropriate laterality modifier to be appended to the code when billed. However, CPT 27130 was not billed with a required appropriate modifier in this claim. Therefore this service is not eligible for reimbursement consideration.  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 orthopedic surgery (procedure code 27130) provided to the enrollee on August 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided on July 28, 2021.  You asked the Plan to pay for the core buildup. You say that prior to this service being rendered you contacted the Plan and were advised that you do have coverage for dental services that are rendered out-of-network. The Plan denied your request. The Plan says this service is not a covered expense under your dental plan. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.  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 pay for the core buildup, including any pins when required (D2950) provided on July 28, 2021.