Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a gradient sequential lymphedema pump to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the OON gradient sequential lymphedema pump. You say that you are the only provider who can supply the enrollee with this type of pump, as it has clearing mode and focal mode which tenderizes fibrotic tissue and mimics manual lymphatic drainage, opening up alternative path while clearing the lymphatic pathways. The Plan denied your request. The Plan says an advanced pneumatic compression device and accessories are medically necessary and 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 at issue in this appeal. The records provided did not include any objective data to support there is a difference between the requested brand and the preferred brand. The medical records do not document an argument as to why the in-network provider's device cannot be tried. We found no exception that would require the Plan to pre-approve the requested item from an out of network provider. Therefore, we decided that the Plan does not have to pre-approve a gradient sequential lymphedema pump 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 pay for a tubing extension set (S1015) and infection control supplies (S8301) provided June 30, 2021.  You asked the Plan to pay for a tubing extension set and infection control supplies. You say that you are a mobile unit and provided supplies at your own expense. The Plan denied your request. The Plan says these items/services are not separately payable.  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 codes S1015 and S8301 are not supported for separate payment. Specifically, these codes are not separately paid by Medicare. Medicare uses another code for reporting of, and payment for, these services.    Based on this information, we decided that Medicare rules for coverage of a tubing extension set and infection control supplies have not been met. Therefore, we decided that the Plan does not have to pay for a tubing extension set (S1015) and infection control supplies (S8301) provided June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a specialist office visit (99214, 81002, G8417, G8427, G9902) provided on June 16, 2021, by an OON provider.  You asked the Plan to pay for a specialist office visit. You say that pre-authorization and/or pre-certification was not obtained at the time of treatment from your company because of the patient medical condition. You also say that your office tried to obtain the retro authorization for this service, but the Plan has denied as they will not do the retro authorizations. The Plan denied your request. The Plan says this provider is not contracted, and prior authorization was not obtained from the Plan. The Plan also says that the services provided were not urgent or emergent and could have been provided by a contracted provider.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a specialist office visit (99214, 81002, G8417, G8427, G9902) provided on June 16, 2021, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Fentanyl.  You asked the Plan to pre-approve Fentanyl. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.  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 Fentanyl.   Benefits for Fentanyl 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: 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 need inpatient rehabilitation services to regain your strength and would prefer to be transferred within the same hospital facility rather than being moved to a skilled nursing facility. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your ongoing skilled therapy and nursing needs can be provided at a lower level of care.  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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 We decided that the Plan has to pre-approve the Contour OneTouch blood glucose test strips.  You asked the Plan to pre-approve the Contour OneTouch blood glucose test strips. You say that the specific brand of test strips is medically necessary over the Plan's preferred brand. The Plan denied your request. The Plan says that this is not the preferred brand of test strips the Plan requires.  The Plan follows Medicare rules. Medicare rules say that the Plan may limit DME to preferred brands as long as the conditions listed in the Medicare rules section are met.  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 Contour OneTouch blood glucose test strips. Our reviewer says that the requested Contour OneTouch test strips are medically reasonable and necessary. Our physician reviewer found the enrollee is a 59 year old female with type 1 diabetes mellitus currently on the Medtronic 670 G insulin pump. In this case, the pump the enrollee currently has uses the requested Contour OneTouch test strips; the blood glucose data goes straight from the meter to the pump system and hence facilitates proper and seamless functioning of the hybrid closed loop system. Without the blood glucose data, the hybrid closed loop system shifts out of auto mode.  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 Contour OneTouch blood glucose test strips have been met. Therefore, we decided that the Plan has to pre-approve the Contour OneTouch blood glucose test strips.   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 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 the enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee's medical needs are being met in the current acute setting. The LTACH would provide no additional services. With more time in the current setting, clinical stability can be ensured such that the appropriate lower level of care can be determined.  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 LTACH services. 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 she is 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power seat elevation system.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature.  We looked at the file and Medicare rules. The item at issue is a power seat elevation feature. This is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the angiography services coded 75716 provided on May 7, 2021.  You asked the Plan to pay for the angiography services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.  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, we have confirmed that code 37225 is a column II code to column I code 75716. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the angiography services coded 75716 provided on May 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided on March 23, 2021, and March 24, 2021.  You asked the Plan to pay for the self-administered drugs. The Plan denied your request. The Plan says the records show that you were given medications to take orally. The Plan also says that self-administered drugs are not covered under your benefits.  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 pay for the self-administered drugs provided on March 23, 2021, and March 24, 2021.   Benefits for the self-administered drugs 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 pay for a CPAP device (E0601) purchased on August 12, 2021.  You asked the Plan to pay for a CPAP device. You say that the medical device at issue is required for your care. The Plan denied your request. The Plan says rules for payment have not been met because the supplier of the item at issue is not enrolled in the Medicare program.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a CPAP device (E0601) purchased on August 12, 2021.   Your complaint about receiving erroneous or incomplete information about your benefits from representatives of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for ultrasound services provided to the enrollee on September 29, 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 the appropriate modifier was not billed in this case.  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, we have confirmed that code 76705 is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for ultrasound services provided to the enrollee on September 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve outpatient surgery to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve outpatient surgery to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.  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 outpatient surgery to be provided by an out-of-network (OON) provider.
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 enrollee would benefit from intensive therapy and will be best serviced in an IRF. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee would be better suited with a less intensive therapy program in a lower level of care.  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 based on the medical records provided, the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the enrollee does require physical therapy and occupational therapy services, the enrollee does not require an intensive inpatient rehabilitation therapy program provided in an IRF based on the records provided. Care at the skilled nursing facility level appears 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an out-of-network referral for bronchoscopy for the enrollee.  You asked the Plan to pre-approve the referral. You say that there are not many providers in the area that can do the bronchoscopy. The Plan denied your request. The Plan says this does not meet the requirements for approval.  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 out-of-network referral for bronchoscopy for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acetaminophen (Apap) and codeine.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.    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 acetaminophen (Apap) and codeine.   Benefits for these services 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 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's ongoing care needs. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee is receiving medically necessary acute and/or critical care. The enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which an LTACH may offer a therapeutic advantage. The Plan will continue to cover medically necessary acute and critical care at the current facility until the enrollee's condition is stable for transfer to a lower level of care or until the clinical circumstances change.  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 LTACH services. 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 he/she is 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 LTACH services.