Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power seat elevation system (E2300) for use with a power wheelchair (PWC).You asked the Plan to pre-approvethe power seat elevation system. You say that it is felt that this feature is medically necessary.The Plan denied your request. The Plan says this is not considered primarily medical in nature and cannot be covered.The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature.Although this feature may be appropriate, it is not among the items for which Medicare payment can be made.Therefore, we decided that the Plan does not have to pre-approvea power seat elevation system (E2300) for use with a power wheelchair (PWC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement power scooter.
You asked the Plan to pre-approve the power scooter. You say that you believe that this is needed to assist with
your mobility. The Plan denied your request. The Plan says the records show that you have normal upper
extremity strength and could use a manual wheelchair in the home. A power scooter is requested mostly for use
outside the home.
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 power scooter. Our reviewer says
that the documentation does not support that a PMD is medically reasonable and necessary in this case. Our
physician reviewer found the documentation does reveal that the patient has a personal mobility deficit, but it is
not clear that this deficit impairs participation in MRADLs in the home or why the mobility deficit is unable to
be helped by a manual wheelchair. The patient was noted to have the upper extremity strength to self-propel a
manual wheelchair in the home to perform MRADLs per a physician document on 10/20/20. The
documentation reveals the patient has the vision to safely operate a scooter but there is no in person
assessment in the home to evaluate that he can safely maneuver the PMD in the home and that it will
significantly improve MRADLs in the home.
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 power scooter have not been met. Therefore, we decided that the Plan does
not have to pre-approve a replacement power scooter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe positron emission tomography (PET) scan you had on February 10, 2020.You asked the Plan to waive the copayment forthe PET scan. You say that you believe you had met your out-of-pocket maximum, so you shouldn't have to pay this copayment.The Plan denied your request. The Plan says you did not meet your out-of-pocket maximum until June 25, 2020, which is after the date of service for this PET scan.  The Plan says that you were charged this copayment correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for diagnostic and nuclear medicine radiological services. You have been asked to pay a $150 copayment for the PET scan. The PET scan falls within the diagnostic and nuclear medicine radiological services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The records show that you had not met your out-of-pocket maximum as of this date of service. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe positron emission tomography (PET) scan you had on February 10, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 21, 2020, by an OON provider.
You asked the Plan to pay for nursing facility practitioner care. You say that these medically necessary services were provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment have not been met.
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 has network providers available who can provide 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 the medical services provided on May 21, 2020, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided July 8, 2020.
You asked the Plan to pay for the ambulance response and treatment, no transport. You say that please help pay for this fracture. The Plan denied your request. The Plan says this service is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 8, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided July 8, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for thyroid testing received on January 30, 2020.
You asked the Plan to pay for the testing. You say that you were not told that this would not be eligible for payment. The Plan denied your request. The Plan says that this is not a covered benefit.
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan has not submitted any medical records for review to see if the testing at issue in this case was medically necessary. Additionally, you say your doctor referred you for these services. The plan does not specify in the case file; however, it's likely that "your doctor" is within your plan's network. Therefore, you should be held harmless for these services. The plan did not substantiate their denial with sufficient information. Therefore, we decided that the Plan has to pay for thyroid testing received on January 30, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 does 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. The medical record supports a need for physical and occupational therapy but it does not support a need for 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 anIRF.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 inpatient rehabilitation facility (IRF) admission and services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveperiodontal scaling and root planing-four or more teeth per quadrant tooth number UL (D4341).You asked the Plan to pre-approvedental services for the enrollee. You say that these dental services are medically necessary.The Plandenied your request. The Plan says the dental 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 dental services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation submitted does not support the criteria for coverage for D4341, scaling and root planing-four or more teeth per quadrant, of the maxillary left quadrant since only three teeth are noted.Medical necessity has not been established. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of dental services have not been met.Therefore, we decided that the Plan does not have to pre-approvedental services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe office visit and visual field examination (99213, 92083) provided on July23, 2020.You asked the Plan to waive the coinsurance forthe office visit and visual field examination. You say that you do not believe you should have to pay for damage you received in your eye from another provider.The Plan denied your request. The Plan says the coinsurance applied correctly in this case.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare covered vision services. You have been asked to pay a total cost share of $27.85 for the office visit and visual field examination ($139 allowed amount x 20% = $27.85). The services provided fallwithin the Medicare covered vision services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forthe office visit and visual field examination (99213, 92083) provided on July 23, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the eye refraction (99348) provided on July 28, 2020.
You asked the Plan to pay for eye refraction. You say that you are allowed one routine eye exam a year. The
Plan denied your request. The Plan says that this service is not covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers one routine vision exam per year (including eye refraction for eyeglasses/contact
lenses).
We looked at the file and the Plan's rules. The record does not show that you exhausted your benefit for one
routine eye exam in the 2020 calendar year. Based on this information, we decided that the Plan's rules for
coverage of eye refraction have been met. Therefore, we decided that the Plan has to pay for the eye refraction
(99348) provided on July 28, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional occupational therapy visits.
You asked the Plan to pre-approve 10 additional occupational therapy visits. You say that the 10 additional occupational therapy visits are medically necessary. The Plan denied your request. The Plan says the 10 additional occupational therapy visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 10 additional occupational therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had prior therapy for this condition and it does not appear that the enrollee's functional level requires the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The enrollee's plan of treatment and treatment services was reviewed with interdisciplinary team members. The specialized skill,
knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 10 additional occupational therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional occupational therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on July 28, 2020 by an out of network provider.You asked the Plan to pay forthe laboratory services. You say that the Plan should pay this claim.The Plan denied your request. The Plan says you did not request prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The 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. 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 forthe laboratory services provided on July 28, 2020 by an out of network provider
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from December 21, 2019, through December 23, 2019.You asked the Plan to pay forthe acute inpatient hospital care. You say that the inpatient hospital care provided was medically necessary for the enrollee.The Plan denied your request. The Plan saysthat the inpatient hospital care provided was not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the emergency room on December 21, 2019 after a syncopal episode. Evaluation revealed a blood pressure of 60/40. She was treated with IV fluids and admitted. She was then evaluated by Cardiology. After a complete evaluation with laboratory studies, she was felt to have orthostatic hypotension. She did have guaiac positive stool but a stable hematocrit count. She was treated with Midodrine and her condition stabilized and improved. She was discharged when considered medically stable on December 23, 2019. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the acute inpatient hospital care have been met.
Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from December 21, 2019, through December 23, 2019.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses (L1851 and L2397) provided to the enrollee on May
26, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the documentation submitted did not include an itemized shipping or billing invoice to indicate
the specific supplies, or proof of delivery.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Medicare rules say that DME supplies must be provided with a proof of delivery.

We find that HCPCS codes L1851 and L2397 is not supported in the medical record. The required
documentation pertaining to the proof of delivery of these supplies was not provided. 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 pay for orthoses (L1851 and L2397) provided to the enrollee on May 26,
2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan of the abdomen and pelvis (74176) received on July 8, 2020.
You asked the Plan to waive the copayment for a CT scan of the abdomen and pelvis. You say that you did not receive a CT scan of the abdomen and pelvis on July 8, 2020, but a CT scan of the chest. The Plan denied your request. The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $180 copayment for advanced imaging services at a specialist's office. You have been asked to pay a $180 copayment for a CT scan of the abdomen and pelvis. A CT scan of the abdomen and pelvis falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a CT scan of the abdomen and pelvis (74176) received on July 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe oral exam (D0120) and bitewing x-rays (D0274) provided on September 18, 2020.You asked the Plan to pay forthe dental services. You say that you were advised by a plan representative that the services would be covered.The Plan denied your request. The Plan says $30 is payable for every dental office visit when treatment is received that includes diagnostic and preventive services. The Plan also says bitewing x-rays are not listed as a covered service.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, there is a $30 office visit fee when treatment is received. Additionally, the bitewing x-rays are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe oral exam (D0120) and bitewing x-rays (D0274) provided on September 18, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.

You asked the Plan to pre-approve Keytruda. You say that the requested Keytruda is medically necessary. The
Plan denied your request. The Plan says the requested Keytruda is not medically necessary.

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 Keytruda. Our reviewer says that the
requested Keytruda is not medically necessary. Our physician reviewer found the enrollee is with metastatic
non-small cell lung cancer with progression of disease while on Imfinzi. As the enrollee has previously failed
PD inhibitor, cannot approve further PD inhibitor with Keytruda.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda.