Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare criteria for home physical therapy services are not met and medical necessity is not established.

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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found there are no documented home health physical therapy needs. You appear to be functioning at a level commensurate with a lower level of care, such as a home exercise program or outpatient therapy. As such, the requested therapy 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health physical therapy.
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 are a fall risk and do not feel safe at home. You need IRF services to regain your strength. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. While you would benefit from physical and occupational therapy, you do not require an intensive team and program for you to reach your functional goals. The services you need can be provided in a less intensive setting.

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 documentation provided, it does not appear that you require the intensity of services provided in an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needs can be provided in an alternate 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 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a root canal (endodontic therapy) (D3320) for tooth # 21.  You asked the Plan to pre-approve a root canal. You say that you need this service. The Plan denied your request. The Plan says root canal is not 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 requested root canal is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a root canal (endodontic therapy) (D3320) for tooth # 21.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

We decided that the Plan does not have to pre-approve the UbiDuo3 speech generating device to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the UbiDuo3 speech generating device to be provided by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the UbiDuo3 speech generating device is being requested due to its ability to allow for two-way communication between a deaf/speech impaired member and the intended listener. The Plan agrees that a speech generating device is medically necessary in this case. However, the Plan has network providers that can provide a device that serves the same purpose as the requested device. The main difference between the requested UbiDuo3 device and the Plan's network device is the UbiDuo3 device has two keyboards versus one keyboard with the network device. Having two separate keyboards, one for the deaf/speech impaired member and one for the intended listener is not medically necessary versus the Plan's network device that has one keyboard that is shared by both the deaf/speech impaired member and the intended listener.

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 a medically necessary speech generating device that meets the enrollee's needs. We found no exception that would require the Plan to pre-approve these items/services with an OON provider. Therefore, we decided that the Plan does not have to pre-approve the UbiDuo3 speech generating device to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Otezla tablets.  You asked the Plan to pre-approve self-administered drug. You say that the enrollee has been on this medication with a good outcome. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug 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 pre-approve Otezla tablets.   Benefits for self-administered drug 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the medical services associated with a clinical trial.  You asked the Plan to pre-approve the medical services associated with a clinical trial. You say that these services are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says care associated with a clinical trial is covered by Original Medicare.  The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services.  In this case, you asked the Plan to pre-approve the medical services associated with a clinical trial as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve the medical services associated with a clinical trial.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intravenous (IV) moderate (conscious) sedation/analgesia- first 15 minutes (D9239), intravenous (IV) moderate (conscious) sedation/analgesia - each subsequent 15-minute increment (D9243), and removal of torus palatinus (D7472).

You asked the Plan to pre-approve the IV sedation and removal of torus palatinus. You say that you would like these services covered. The Plan denied your request. The Plan says these services are not covered under your benefits.

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 the intravenous (IV) moderate (conscious) sedation/analgesia- first 15 minutes (D9239), intravenous (IV) moderate (conscious) sedation/analgesia - each subsequent 15-minute increment (D9243), and removal of torus palatinus (D7472).
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health services.  You asked the Plan to pre-approve the home health services. You say that the home health services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 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 home health services. Our reviewer says that the home health services are not medically necessary. Our physician reviewer found the records do not show a need for skilled care. There are no skilled nursing or therapy 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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on July 20, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says the $1000 dental benefit was exhausted prior to this date of service.
We overturned the Plans denial due to a lack of claim information in the case file. The Plan requested a
reopen and provided the required information. The Plan provided documentation to show the $1000 dental
benefit was exhausted for services provided on January 12, 2021, January 19, 2021, and February 3, 2021.
The Plan is correct in this case. 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 $1000 benefit was exhausted prior
to the date of service under appeal. Therefore, we decided that the Plan does not have to pay for dental services
provided on July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the requested provider.
You asked the Plan to provide coverage for out of network dermatology. The Plan denied your request. The
Plan says this consultation was available in network. We overturned the Plans denial stating this
consultation was medically necessary. The Plan requested a reopen and stated that the issue was not medical
necessity, but the use of an out of network provider.
The Plan is correct in this case. Medicare rules say that plans can require enrollees to get care from network
providers. The contract with the Plan says that the Plan must 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 was not in network. The Plan has network providers who can provide the
services requested. This was not an urgent or emergent situation that could not be accommodated in network.
We found no exception that would require the Plan to provide coverage for these services. Therefore, we
decided that the Plan does not have to provide coverage for an out of network dermatology consultation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power operated group 1 heavy duty wheelchair for the enrollee.  

You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show an inability to accomplish mobility-related activities of daily living.  

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.    

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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no documentation that this enrollee has a personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming, and bathing in customary locations within the home. The available records indicate the power wheelchair is being requested for use outside the home. There is no documentation that your deficit cannot be helped by the use of a walker. The records report that you can walk from room to room with a walker. There is no documentation that you would be able to safely operate the power wheelchair.  

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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power operated group 1 heavy duty wheelchair for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for testing services (88311) provided on April 2, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. We overturned the Plans denial. The
Plan requested a reopen and provided additional information. The Plan says that this claim is not payable as
billed. The Plan states the provider submitted a taxonomy code that indicated the billing individual was a
student, intern, and/or resident who was not yet licensed. This taxonomy code is not payable, per
the Medicare Provider and Supplier Taxonomy Crosswalk.
The Plan demonstrated that both the claim raw data (showing the taxonomy code submitted electronically by
the provider) and the Medicare Crosswalk show this issue. The Plan states that teaching or student taxonomy
codes are prohibited from payment. The Plan states the provider has the right to submit a corrected claim with
the appropriate taxonomy code for consideration of payment.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
follow correct billing procedures. The taxonomy code submitted by the provider on the claim is not payable
because the services is billed with a non-payable taxonomy code. Medicare rules for coverage of these services
have not been met. Therefore, we decided that the Plan does not have to pay for testing services (88311)
provided to the enrollee on April 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an inpatient psychiatric admission to be provided by a participating provider.  You asked the Plan to pre-approve an inpatient psychiatric admission. You say that you would like approval for this inpatient psychiatric admission. The Plan denied your request. The Plan says the enrollee no longer meets the criteria for this 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 an inpatient psychiatric admission. Our reviewer says that an admission to an inpatient psychiatric admission. Our physician reviewer found the records that were provided show that it was not expected this enrollee would improve in a reasonable period of time. The enrollee did not show dangerousness to self or others and was not showing any auditory/visual hallucinations or any aggressive behaviors  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an inpatient psychiatric admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient psychiatric admission to be provided by a participating provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Vyzulta.  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 Vyzulta.   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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve transcatheter mitral valve repair (TMVR).  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 medically necessary.  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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has severe tricuspid valve regurgitation resulting from previous infective endocarditis. The records are insufficient to support that the requested TMVR is medically necessary for the enrollee's clinical management.          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 transcatheter mitral valve repair (TMVR).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for transitional care management provided January 20, 2021.

You asked the Plan for these services. You say that you do not believe this bill is correct. The Plan denied your
request. The Plan says these services must be addressed under your Medicaid benefit. The Qualified Independent Contractor overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says that this claim
denied under your Medicare benefit because you are Medicaid eligible. The Plan included documentation to
show that you are Medicaid eligible. The Plan says that Medicare pays covered dually eligible beneficiaries'
medical services first, because Medicaid is generally the payer of last resort. Medicaid may cover medical costs
that Medicare may not cover or partially covers (such as nursing home care, personal care, and home- and
community-based services). These services qualified under the Medicaid coverage.

The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are
covered by either Medicare or Medicaid, but not by both.

The services provided fall under your Medicaid coverage and not your Medicare coverage. The IRE does not
have jurisdiction over your Medicaid benefits. Therefore, we decided that the Plan does not have to waive the
copayment for transitional provided January 20, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health physical therapy.  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 medically necessary.  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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have frequently missed home health physical therapy appointments. Despite missing appointments, there is no significant evidence of a decline in function. You are ambulating at a level that does not require home health care. The home health physical therapy 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 home health physical therapy.