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

We decided that the Plan does not have to pre-approve a surgical extraction (D7250) and a partial lower denture (D5214).
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says that dental services that you receive out of network are 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 a surgical extraction (D7250) and a partial lower denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour In Vitro diabetic test strips.

You asked the Plan to pre-approve the Contour In Vitro brand test strips. You say that you wish to use this brand because you have been using it. The Plan denied your request. The Plan says your Plan offers equivalent test strips at no cost from a preferred brand. There is no evidence that you require the non-preferred brand.

The Plan must follow Medicare rules. Medicare rules say that Plans may restrict enrollees to certain brands of equipment as long as non-preferred brands are available if medically necessary.

No documentation was submitted to support that the non-preferred brand is medically necessary over the preferred brand. Therefore, we decided that the Plan does not have to pre-approve Contour In Vitro diabetic test strips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve companion diagnostic testing (KRAS, NRAS) for the enrollee.

You asked the Plan to pre-approve the testng. You say that the enrollee's melanoma is pathological stage 3C. The Plan denied your request. The Plan says BRAF mutation analysis is recommended, but KRAS and NRAS are not.

The Plan must follow Medicare rules. The rules say that NRAS and KRAS testing is covered for colorectal cancer. 

The NRAS and KRAS testing cannot be approved, as multiple myeloma is not the covered diagnosis for this testing. Based on this information, we decided that Medicare rules for coverage of the testng have not been met. Therefore, we decided that the Plan does not have to pre-approve companion diagnostic testing (KRAS, NRAS) for the enrollee.
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 LTACH services are medically necessary. The Plan denied your request. The Plan says coverage rules have not been met.
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 evidence that the enrollee requires services that are not currently available. The enrollee can remain at the current acute care hospital until such time no acute services are required. The enrollee can then be discharged to a lower level of care for any ongoing Long-term-care 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the medical services provided on September 18, 2020, by an in-network provider.
You asked the Plan to waive the cost share for the medical services. You say that you went for a cardiovascular consultation. You state it was not explained to you that there would be an additional cost-share for the tests performed. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received medical services provided on September 18, 2020, by an in-network provider. The provider billed cardiovascular stress test (Current Procedural Terminology (CPT) code 93015) with a billed amount of $154. The allowed amount is $63.23. You have a $30 copay for non-radiological diagnostic services. The remaining $33.23 was paid to the provider. The provider billed rubidium Rb-82, diagnostic (CPT Code A9555) with a billed amount of $2,083. The allowed amount is $1,014.50. You have a 20% coinsurance for Medical Supplies, which came out to $208.30 ($1,041.50 x .20 = $208.30). The remaining $833.20 was paid to the provider. The provider billed Regadenoson 0.1MG Injection (CPT Code J2785) with a billed amount of $440. The allowed amount is $237.48. You have a 20% coinsurance for Part B Drugs, which came out to $47.50 ($237.48 x .20 = $47.50). The remaining $189.98 was paid to the provider. The provider billed Myocardial imaging, positron emission tomography (PET), perfusion study (CPT Code 78492) with a billed amount of $2,654. The allowed amount is $1,031.91. You have a $125 copay for radiological diagnostic services. The remaining $906.91 was paid to the provider. Your total copayment for this date of service is $410.80. You are responsible for a cost share per the plans benefits for Part B drugs, Medical Supplies, non-radiological diagnostic services, radiological diagnostic services.
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 cost share for the medical services provided on September 18, 2020, by an in-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110).

You asked the Plan to pre-approve the denture. You say that the member lost their denture which was made in 2019 and is having trouble with daily tasks without it. The Plan denied your request. The Plan says a complete upper denture can only be covered once every five years. This item was previously provided for the member in 2019, which is less than 5 years before this request. Therefore, the upper denture cannot be 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, a denture is requested in a frequency not covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve for admission to a long-term acute care hospital (LTACH) for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show that a breathing machine has been used for a long time (e.g., 21 days).

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 necessitating 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 she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve for admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron.
You asked the Plan to pre-approve Ondansetron. You say that the enrollee will need an anti-emetic to prevent nausea and vomiting. The Plan denied your request. The Plan says Ondansetron to be taken at home is not covered under the Part B benefit.
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 Ondansetron.
Benefits for Ondansetron 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a myeloproliferative neoplasm gene panel.

You asked the Plan to pre-approve the gene panel. You say that the enrollee has elevated hemoglobin and hematocrit. The Plan denied your request. The Plan says the gene testing as part of a panel is 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 the gene panel. Our physician reviewer found that the enrollee has suspected primary erythrocytosis. Routine lab work showed elevated hemoglobin and hematocrit. A myeloproliferative gene panel is not medically reasonable and necessary for the enrollee in this case. A stepwise approach to testing may be considered. 

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 gene panel have not been met. Therefore, we decided that the Plan does not have to pre-approve a myeloproliferative neoplasm gene panel.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay 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 the health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care.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-approveacute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea prefabricated post and core in addition to crown (D2954) for tooth #5.You asked the Plan to pre-approvethe prefabricated post and core. You say that your tooth needs an emergency crown so that the tooth will not be abscessed, and you also need a root canal.The Plan denied your request. The Plan says since a core buildup, including any pins when required (D2950) has been approved for tooth #5, a prefabricated post and core in addition to crown (D2954) for tooth #5 is not medically necessary.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. The Plan covers the prefabricated post and core when the services are medically necessary and reasonable. 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 prefabricated post and core. Our reviewer says that the post and core is not medically necessary. Our physician reviewer found tooth #5 has lost one cusp and is heavily broken down. The tooth has been approved for a core buildup and a crown. A post and core foundation restoration can onlybe placed where the root canal has been cleaned and shaped as the post fits into the canal space. Our reviewer found that tooth #5 has not had endodontic treatment and a post cannot be placed in this situation. The core buildup is the proper procedure to be used in cases such as this where there is substantial loss of structure but no accessible root canal to place a support into. The provider had stated the tooth has a good endodontic and periodontal prognosis. Our physician reviewer also found that a post and core would not be possible. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the prefabricated post and core have not been met.Therefore, we decided that the Plan does not have to pre-approvea prefabricated post and core in addition to crown (D2954) for tooth #5
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services after May 7, 2021
You asked the Plan to pre-approve continued SNF services after May 7, 2021. You say that you need continued services. The Plan denied your request. The Plan says the enrollee does not need continued skilled nursing or therapy services.
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 pre-approve continued SNF services after May 7, 2021. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this patient does not require ongoing skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to provide medically necessary and reasonable treatment safely and effectively in a SNF beyond the last covered date. The patient has no complex wound care or other SN need. The patient's functional level does not require ongoing skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to provide medically necessary and reasonable treatment safely and effectively in a SNF. Skilled nursing or therapy services are not required on a "daily basis" or as a practical matter on an inpatient basis, in a skilled nursing facility setting beyond the last covered date.
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 SNF services after May 7, 2021 have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services after May 7, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational.

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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy.

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power wheelchair and related accessories.
You asked the Plan to pre-approve a group 2 power wheelchair and related accessories. You say that the requested wheelchair is medically necessary. The Plan denied your request. The Plan says the criteria for the wheelchair have not been met.
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 a group 2 power wheelchair and related accessories. Our reviewer says that the requested wheelchair is not medically necessary and reasonable. Our physician reviewer found the documentation does not support that the patient has a mobility limitation that significantly impairs her ability to participate in one or more mobility-related activities of daily living such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. Nurse practitioner physical examination dated October 5, 2020, reveals that the patient has normal upper and lower extremity (5/5) muscle strength, normal range of motion, gait is normal and is able to tandem walk. The documentation is conflicting on patient's function, but the physical examination does not support a mobility limitation that requires a Group 2 power wheelchair. The documentation does not reveal that the patient's mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker or even manual wheelchair that is properly fitted. The documentation does not reveal that the use of the wheelchair will significantly improve the patient's mobility-related activities of daily living. As the requested group 2 power wheelchair is not medically necessary the related accessories will be denied as not reasonable and 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 a group 2 power wheelchair and related accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair and related accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor.

You asked the Plan to pre-approve the therapeutic continuous glucose monitor. You say that you would like the Plan to reconsider their denial based on medical necessity. The Plan denied your request. The Plan says the rules for a therapeutic continuous glucose monitor 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 perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

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 the therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea dental bridge.You asked the Plan to pre-approvea dental bridge between teeth #8 and #10. You say that the enrollee needsa bridge. The Plandenied your request. The Plan says information sent does not tell us why a denture cannot be used to replace missing teeth.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. The Plan covers a dental bridge when the services are medically necessary and reasonable. We looked at the fileand Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a dental bridge have not been met.Therefore, we decided that the Plan does not have to pre-approvea dental bridge and extraction.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Adcetris (J9042).

You asked the Plan to pre-approve Adcetris. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the requested drug would be deemed a routine cost covered by the Medicare Administrative Contractor (MAC).

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 Adcetris 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 Adcetris (J9042).