Persius/hicric huggingface dataset:
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 these services are medically necessary. The Plan denied your request. The Plan says that your records do not show that the ongoing care you need can only be given in a hospital setting.  

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. You were admitted following a fall and head injury. The record indicates that you had exposed hardware on the scalp and required surgical debridement and hardware removal as well as intravenous antibiotics. The record indicates that you require ongoing acute care services before being able to be discharged to a lower level of care. You continued to receive acute care services, and these have not been denied. The medical record does not indicate that you require services that he is not currently receiving but that would be available at the LTACH facility. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH 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 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an apicoectomy; first root (D3421), and apicoectomy; each additional root (D3426) to be provided by an out of network provider.  You asked the Plan to pre-approve the dental services. You say that you have anxiety about going to new doctors. You say that you have established care with the doctors in this office. You say that this dental office is closest to you. You also say that you you would not be able to drive to any other offices. The Plan denied your request. The Plan says there are in network providers available that can provide these services.  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, dental services are only covered when received by a participating provider. Additionally, the record shows that the Plan confirmed there are in network providers available within a 10 mile radius. Therefore, we decided that the Plan does not have to pre-approve an apicoectomy; first root (D3421), and apicoectomy; each additional root (D3426) to be provided by an out of network provider.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health aide or certified nurse assistant, providing care in the home, per hour (S9122).  You asked the Plan to pre-approve home health aide services. You say that you had a total hip replacement surgery. You say that you require assistance to get out of bed. You also say that you require a walker to walk. The Plan denied your request. The Plan says the requested home health aide services are not medically necessary.  The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.   We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met. Specifically, the file shows that you do not require skilled services. The record shows that the requested home health aide services are to aid with activities of daily living (ADLs). Therefore, we decided that the Plan does not have to pre-approve home health aide or certified nurse assistant, providing care in the home, per hour (S9122).
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) (G0299).  

You asked the Plan to pre-approve the direct skilled nursing services of a RN. The Plan denied your request. The Plan says being alone and a need for vital signs (for unclear medical reasons) are not sufficient for the necessity to continue home health. The Plan also says that you do not require further therapy as you were discharged from physical therapy due to goals being met.  

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 direct skilled nursing services of a RN. Our reviewer says that the requested home health skilled nursing services are not medically necessary or reasonable. Our physician reviewer found you do not have documented skilled nursing 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 direct skilled nursing services of a RN have not been met. Therefore, we decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) (G0299).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing facility (SNF) admission provided from July 14, 2021, to July 20, 2021.  You asked the Plan to pay for the SNF admission from July 14, 2021, to July 20, 2021. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says there was no skilled therapy was given beyond July 13, 2021. The Plan also says that the enrollee did not have skilled nursing 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 pay for the SNF admission from July 14, 2021, to July 20, 2021. Our reviewer says the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF admission from July 14, 2021, to July 20, 2021, have not been met. Specifically, the file shows that the enrollee did not receive any skilled services. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) admission provided from July 14, 2021, to July 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CPAP device (E0601).

You asked the Plan to pre-approve a CPAP device. You say that your non-compliance with the CPAP device was temporary due to facial swelling from a fall. The Plan denied your request. The Plan says rules for coverage for the requested item have not been met.

The Plan must follow Medicare rules. Medicare rules say that continued coverage of a CPAP device require use of PAP greater than or equal to 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CPAP device have not been met. Specifically, the provided CPAP compliance report does not document adherence to PAP therapy. The provided medical records do not support that your non-adherence was due to a medical injury or condition. Therefore, we decided that the Plan does not have to pre-approve a CPAP device (E0601).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a knee scooter.  You asked the Plan to pre-approve a knee scooter. You say that you recently broke your ankle and require a knee scooter to get around. The Plan denied your request. The Plan says the requested item is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that knee scooters (crutch substitutes) are not covered.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a knee scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor.  

You asked the Plan to pre-approve a continuous glucose monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements for coverage have 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 use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient services provided October 20, 2020 to October 23, 2020. 
 
You asked the Plan to pay for the inpatient services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.  

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 the inpatient services are not supported in the medical record. Specifically, these services were billed with a provider Medicare identification number that doesn't start until October 29, 2020. The services were performed from October 20, 2020 to October 23, 2020. This means this claim was billed with an incorrect Medicare identification number. Based on this information, we decided that Medicare rules for coverage of the inpatient services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient services provided October 20, 2020 to October 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve computed tomographic angiography, abdomen and pelvis (74174), and computed tomographic angiography, abdomen (74175)  

You asked the Plan to pre-approve the diagnostic service. You say that even though the CTA was performed in October, it was not a CTA stent protocol which is specific to status post EVAR to get the best imaging and focusing on contrast within the endograft and specifically looking for any endoleak. The Plan denied your request. The Plan says repeat imaging is not supported without results of the prior imaging that show a clear reason for it.  

The Plan must follow Medicare rules. Medicare rules say that CT scans 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 diagnostic service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the request for CTA abdomen and pelvis and abdomen has been denied as the enrollee recently had the same or similar study done in October 2021. The records do not show that there has been a change in her condition since that time. The prior study showed her provider what they needed to see to treat her condition. The records do not show a clear reason for the repeat study. The review has determined that the requested CTA scan is not medically reasonable or 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 diagnostic service have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomographic angiography, abdomen and pelvis (74174), and computed tomographic angiography, abdomen (74175)
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pre-approve inpatient rehabilitation facility (IRF) services.  You asked the Plan to pre-approve IRF services. The Plan denied your request. The Plan says that the documentation does not show that the enrollee's care cannot be provided at a lower level of care.  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.  We looked at the file and the rules. The case summary in the file makes note of a pre-admission assessment, physical therapy and occupational therapy notes. However, medical records were not provided. We requested medical records from the Plan on multiple occasions, yet none were presented. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pre-approve inpatient rehabilitation facility (IRF) services.   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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve four gingivectomies (D4210 x4).  

You asked the Plan to pre-approve the gingivectomies. You say that gingivectomies are recommended because the condition did not improve even after scaling and root planing procedure. The Plan denied your request. The Plan says this service is not covered.  

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 pre-approve four gingivectomies (D4210 x4).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for genetic testing (81479) provided on March 17, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for genetic testing. You say that this was medically necessary. The Plan denied your request. The Plan says this was not authorized.  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 genetic testing (81479) provided on March 17, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Tecentriq 1200 mg/20 mL intravenous solution (J9022).  

You asked the Plan to pre-approve Tecentriq. You say that it was recommended that this enrollee's disease be treated with the combination of Carboplatin, Etoposide, and Tecentriq. The Plan denied your request. The Plan says the enrollee is using this drug for neuroendocrine carcinoma, which is not a medically accepted indication.  

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Tecentriq. Our reviewer says that the elements of the coverage criteria are not satisfied. Our physician reviewer found the record indicates that the enrollee has a diagnosis of stage IV rectal cancer with a mixed tumor histologically including adenocarcinoma and neuroendocrine cells with neuroendocrine metastases to the liver. Our reviewer found that the Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Our physician reviewer also found that no literature from Medicare approved cancer journals were submitted for review.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Tecentriq have not been met. Therefore, we decided that the Plan does not have to pre-approve Tecentriq 1200 mg/20 mL intravenous solution (J9022).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the remaining extractions provided on July 20, 2021.  

You asked the Plan to pay for the remaining extractions. You say that most of the teeth were broken off and decayed. The Plan denied your request. The Plan says your calendar year maximum 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.     

Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum allowance of $2,000 every calendar year for covered dental services. The Plan paid $1,614 for the dental services provided on July 20, 2021, which met your $2,000 maximum. You are responsible for any amount over the allowance amount. Therefore, we decided that the Plan does not have to pay for the remaining extractions provided on July 20, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Avsola (Q5121).  You asked the Plan to pre-approve Avsola. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been met.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Avsola. Our reviewer says that the requested drug is not medically reasonable and necessary based on Medicare rules. Our physician reviewer found the Plan requires a trial of Remicade, Inflectra, infliximab or Simponi Aria before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Avsola have not been met. Therefore, we decided that the Plan does not have to pre-approve Avsola (Q5121).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for home health physical therapy services provided from February 12, 2020, through March 5, 2020.  You asked the Plan to pay for home health physical therapy services. You say that the claims should be covered. The Plan denied your request. The Plan says the claim denied in full as non-contract provider liability for untimely filing of the claim.  The Plan must follow Medicare rules. The rules say that claims for services furnished on or after  January 1, 2010 must be filed no later than one calendar year after the date of service. The rules also say non-contract providers must accept as payment in full payment amounts applicable in Original Medicare. In addition, under Federal law, non-contract providers are subject to penalties if they accept more than Original Medicare amounts. We looked at the file and Medicare rules. In this case, the non-contract provider failed to submit a clean claim to your Plan within one calendar year of the dates of service. This means that the services cannot be reimbursed by Medicare, meaning the Medicare-allowed amount of the services rendered is $0. The Plan is not obligated to make payment for claims submitted after one calendar year, and the provider is not allowed to bill you for these services. Therefore, we decided that the Plan does not have to pay for home health physical therapy services provided from February 12, 2020, through March 5, 2020.