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 IRF care is medically necessary. The Plan denied your request. The Plan says under Medicare, the request is 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 considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that 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. Medical
problems are stable. There are no complex nursing or rehabilitation needs. 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 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the OON therapeutic services. You say that the medical records provided support the need for the services in dispute. The Plan denied your request. The Plan says they have a participating provider who is willing to travel to the enrollee's residency to prove the requested services. The Plan says that the OON provider does not provide any specialty services that the participating provider cannot supply. The Plan says that they do not have a network deficiency.

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 therapeutic services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a rowing club membership (A9270) for the 2020 benefit allowance.

You asked the Plan to reimburse you for a rowing club membership. You say that this should be covered because rowing is a fitness activity. You also say that if you go to the gym and work out, that is it covered, but a rowing activity which is better exercise, is not. The Plan denied your request. The Plan says this service is not a covered benefit.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that the Plan reimburses you up to $300 each calendar year towards your cost for membership in a qualified health club or fitness facility, covered instructional fitness classes and participation in wellness programs. 

The Plan's rules for coverage of gym benefits have not been met because a rowing club membership is not a covered benefit of Medicare or the Plan.

Therefore, we decided that the Plan does not have to reimburse you for a rowing club membership (A9270) for
the 2020 benefit allowance.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional mileage allowance for transportation services (A0170).

You asked the Plan to pre-approve an additional mileage allowance for transportation services. You say that you need to get to your medical appointment. The Plan denied your request. The Plan says you benefit only allows 36 one-way trips with each one-way trip not exceeding 50 miles of driving distance.

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. The Plan covers routine transportation when the driving distance for a one-way trip is within 50 miles.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, the provider is located 136 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we decided that the Plan does not have to pre-approve an additional mileage allowance for transportation services (A0170).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 20 transportation trips (A0100).
You asked the Plan to pre-approve an additional 20 transportation trips. You say that you need transportation for upcoming appointments. The Plan denied your request. The Plan says you are allowed a total of 20 one-way trips per calendar year. Once you have exhausted those 20 one-way trips, you are not eligible for addition transportation trips until the beginning of the next year.
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. The Plan covers a maximum of 20 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve an additional 20 transportation trips (A0100).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (99232) provided on April 7, 2021.

You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the records reviewed included a visit performed by this provider on a different date of service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We find that CPT code 99232 is not supported in the medical record. Specifically, the documentation does not support that subsequent hospital care was rendered by this provider on the billed date of service. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care have not been met. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (99232) provided on April 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT).

You asked the Plan to pre-approve PBRT. You say that PBRT is medically reasonable and necessary. The appellant says that this is a Medicare covered treatment. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that PBRT is not the standard of care for prostate cancer and PBRT for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 PBRT. Our reviewer says that PBRT is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a possible advantage of this therapy. Other treatment approaches are highly effective and well tolerated.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT).
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 the enrollee needs LTACH services to continue their care. The Plan denied your request. The Plan says the criteria for an LTACH have not been met, and the enrollee's medical needs are being met in the current acute setting. An LTACH would provide no additional services. With additional 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 admission to a LTACH. 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 they are 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: 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 were independent before your hospitalization and you would like to return to being independent. You also say 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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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: Unfavorable

We decided that the Plan does not have to pre-approve a transfer bench for tub or toilet.
You asked the Plan to pre-approve a transfer bench. You say that it is very difficult for you to bathe because of your medical condition. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that transfer benches are not covered because they are not primarily medical in nature. While a transfer bench may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a transfer bench for tub or toilet.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140), the panoramic x-ray (D0330), core build up (D2950 x 4), retainer crowns (D6740 x 4), and pontics (D6245 x 2) provided from September 17, 2020, to October 13, 2020.

You asked the Plan to reimburse you for the dental services. You say that you sustained serious injuries as a result of a fall last September. You say that you do not understand why the plan has not processed this claim as an accident under your medical coverage. You also say that these services were necessary to repair damaged teeth and upper front facial bone. The Plan denied your request. The Plan says the services you received are dental in nature. The Plan says that routine dental services are not covered by Medicare. The Plan says that the limited oral evaluation and the panoramic x-ray are covered under your supplemental dental plan. The Plan also says that crowns and pontics are not listed as covered under your supplemental dental plan.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Though the Plan offers a dental benefit in excess of Medicare coverage, the retainer crowns and pontics are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140), the panoramic x-ray (D0330), core build up (D2950 x 4), retainer crowns (D6740 x 4), and pontics (D6245 x 2) provided from September 17, 2020, to October 13, 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 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that this patient 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular testing (81291, 81407, 81408, 81439, 81479) provided on March 19, 2021.
You asked the Plan to pay for hereditary cardiovascular testing. You say that this is supported by the records. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of hereditary cardiovascular testing have not been met. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular testing (81291, 81407, 81408, 81439, 81479) provided on March 19, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the HHA or CNA services provided from January 5, 2020, to December 31, 2020.
You asked the Plan to pay for the HHA or CNA services. The Plan denied your request. The Plan says these services were non-skilled, custodial in nature, and are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the HHA or CNA services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the HHA or CNA services provided from January 5, 2020, to December 31, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc 850 (J7320).

You asked the Plan to pre-approve Genvisc 850. You say that the enrollee has tried and failed conservative therapy. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred viscosupplements, Monovisc and Orthovisc.

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 Genvisc 850. Our reviewer says that the requested medication, Genvisc 850, is not medically necessary. Our physician reviewer found the provided documentation indicates that the enrollee has not trialed the preferred viscosupplemental treatments, Orthovisc and Monovisc. The reviewer found that the documentation does not outline contraindications or reasons these medications were not considered. Therefore, the reviewer found that Genvisc is not medically reasonable and necessary as step criteria have not been met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Genvisc 850 have not been met. Specifically, the file indicates that the enrollee has not tried and failed the preferred drugs. Therefore, we decided that the Plan does not have to pre-approve Genvisc 850 (J7320).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a CPAP machine provided on January 7, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for a CPAP machine. You say that you lost track of what referrals were made. You say that you thought all the correct referrals were filed. The Plan denied your request. The Plan says there are in-network providers available to provide the durable medical equipment that was needed.

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 CPAP machine provided on January 7, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated abutments (D6056) on teeth #4 and 6,
abutment supported porcelain fused to metal crowns (D6059 x2) on teeth #4 and 6, and pontic (D6240) on
tooth #5 provided on March 3, 2021.

You asked the Plan to pay for the prefabricated abutments, abutment supported porcelain fused to metal
crowns, and pontic. You say that these services are covered by your plan and were medically necessary. The
Plan denied your request. The Plan says the benefit maximum for these services 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, pontics and retainer crowns are limited
to one per tooth per lifetime. The record shows that you received prefabricated abutments (D6056) on teeth #4
and 6, abutment supported porcelain fused to metal crowns (D6059 x2) on teeth #4 and 6, and a pontic (D6240)
on tooth #5 on January 11, 2021, and your pontic benefit for tooth #5 has been exhausted, and your retainer
crowns benefit for teeth #4 and 6 have been exhausted. Therefore, we decided that the Plan does not have to
pay for the prefabricated abutments (D6056) on teeth #4 and 6, abutment supported porcelain fused to metal
crowns (D6059 x2) on teeth #4 and 6, and pontic (D6240) on tooth #5 provided on March 3, 2021.

Please Note: You may contact your provider to inquire why these same services were billed for the same teeth
on two separate dates of service.