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

 We decided that the Plan does not have to reimburse you for the cone beam computed tomography (CT) capture and interpretation (D0366) and implant evaluation (D0043) provided on March 9, 2021.  You asked the Plan to reimburse you for the dental services. You say that the CT capture was done due to special circumstances. You say that you have a very small mouth. You also say that the CT capture was needed to ensure trust and comfort for the surgical implant. The Plan denied your request. The Plan says cone beam CT capture and interpretation 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 cone beam CT and implant evaluation are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the cone beam computed tomography (CT) capture and interpretation (D0366) and implant evaluation (D0043) provided on March 9, 2021.
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve Durolane  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 that the services are not medically necessary.  The Plan must follow Medicare rules. The rules 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 has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that the Durolane is not medically necessary; however, no medical records were received with the case file. Without medical records, a determination based on medical necessity cannot be supported. Therefore, we decided that the Plan has to pre-approve Durolane   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 hospital care.  You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a right shoulder arthroplasty and tenodesis of long tendon of biceps and will need inpatient admission after surgery. The Plan denied your request. The Plan says there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found the enrollee is approved for a right shoulder arthroplasty and tenodesis of long tendon of biceps. The record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve formoterol fumarate for use in a nebulizer.

You asked the Plan to pre-approve the formoterol for nebulizer. You say that this should be approved since the enrollee reported better symptom control with treatment with a nebulizer than with Symbicort. The Plan denied your request. The Plan says the drug is not covered for the enrollee's condition.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 formoterol for nebulizer. Our reviewer says that the requested use of this medication in a nebulizer is not considered medically necessary. Our physician reviewer found the enrollee is a 61-year-old female with shortness of breath related to pneumonia and prior COVID-19 infection. Treatment with nebulized formoterol fumarate has been requested. The drug is not FDA-approved for this indication. Based on the medical records provided and the Medicare-approved major drug compendia, there is no documentation that the requested use of formoterol fumarate is supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal for the enrollee's diagnosis of shortness of breath related to pneumonia and prior COVID-19 infection. As such, this request is deemed not medically necessary.

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 formoterol for nebulizer have not been met. Therefore, we decided that the Plan does not have to pre-approve formoterol fumarate for use in a nebulizer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a FreeStyle Libre 14 day sensor kit.  You asked the Plan to pre-approve a continuous glucose monitors (CGM). You say that the enrollee needs this. The Plan denied your request. The Plan says the criteria for coverage has not been met.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitors (CGM) have not been met. Specifically, the file does not show that the enrollee is using 3 or more insulin shots per day or on an insulin pump. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 14 day sensor kit.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on May 24, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on May 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continuation of inpatient psychiatric care from November 24, 2021, forward.  You asked the Plan to pre-approve continued inpatient psychiatric care. You say that the enrollee is still unsafe to return home and requires continued psychiatric care at the inpatient level. The Plan denied your request. The Plan says the enrollee is noted as no longer be suicidal. She is not psychotic or manic. New treatment was started, and the enrollee has been compliant with no reported adverse effects. The enrollee can be stepped down to a less restrictive level of care.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.  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 continued inpatient psychiatric care. Our reviewer says that the health plan's denial of continued psychiatric services at the inpatient level appears appropriate in this case. Our physician reviewer found that the enrollee was involuntarily admitted to the acute inpatient psychiatric hospitalization on November 12, 2021 with Bipolar Disorder, Current Episode Depressed, Severe, without Psychotic Features and Opioid Use Disorder a history. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was compliant with treatment while not showing any acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she did not have dangerousness to herself or others but was compliant with her treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in question. Based upon review the records provided, this enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of November 24, 2021, forward.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient psychiatric care from November 24, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99310) rendered by the out-of-network (OON) provider on July 16, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  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.  Th provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.  We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99310) rendered by the out-of-network (OON) provider on July 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide coverage for additional routine transportation trips to locations other than your PCP's office.  You asked the Plan to provide coverage for additional routine transportation trips to locations other than your PCP's office. The Plan denied your request. The Plan says there is no exception that would allow the Plan to approve additional rides. Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at your request, the records in the case file, and the rules. The file shows that the Plan provides a maximum of 48 one-way trips to other health care related locations (such as to the pharmacy or specialist appointments). Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips to locations other than your PCP's office.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on November 24, 2020.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 24, 2020.
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 does need 24-hour nursing care because she is unable to perform her activities of daily living without assistance. You also say that it is unsafe to send the enrollee home because she lives by herself and has no one to assist her. The Plan denied your request. The Plan says the enrollee does not appear to need an inpatient rehabilitation level of intensive therapy as the enrollee does not appear to be able to require intensive daily therapy.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  Our physician reviewer also found that there is not a reasonable expectation that this 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 Prolia.  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 step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the Plan's required drug, zoledronic acid. The records do not show that the required drugs would be contraindicated or less effective; therefore, Prolia is not reasonable or medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the dental exam you had on May 19, 2021.  You asked the Plan to waive the copayment for the dental exam. You say that the dentist lied to you and told you that you did not have a copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment per visit for preventive dental services.   You have been asked to pay a $25 copayment per visit for the dental exam. The dental exam falls within the preventive dental services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the dental exam you had on May 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablations (RFAs).  You asked the Plan to pre-approve lumbar facet joint RFAs. You say that all of the requirements for medical necessity are met. The Plan denied your request. The Plan says the denial of authorization for lumbar facet joint radiofrequency ablations is correct, because the records do not show that two medial branch blocks were performed providing at least 80% improvement of pain or at least 50% improvement in the ability to perform activities of daily living (ADLs).  The Plan follows Medicare rules. Medicare rules state that facet joint interventions may be covered under certain clinical conditions.  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 lumbar facet joint RFAs. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested radiofrequency ablations. Our physician reviewer found facet joint injections were performed in 2020 with excellent response, but there have been no facet joint interventions in 2021. Therefore, the enrollee does not meet the coverage indications for the requested radiofrequency ablations.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar facet joint RFAs have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablations (RFAs).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on April 20, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acupuncture services.  You asked the Plan to pre-approve acupuncture. You say that you will be having back surgery, but acupuncture will help mitigate the pain. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the record does not show that you have a history of chronic low back pain.  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.   We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, although the record shows you have low back pain it has not been specified as chronic low back pain. Therefore, we decided that the Plan does not have to pre-approve acupuncture services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Arestin Microsphere.  You asked the Plan to pre-approve Arestin Microsphere. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not been met.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Arestin Microsphere.   Benefits for Arestin Microsphere may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.