Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 20, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 did not pre-approve the laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on October 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Scopolamine.

You asked the Plan to pre-approve Scopolamine. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this drug is not covered under Medicare Part B.

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 Scopolamine.

Benefits for Scopolamine 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the home improvement supplies (S5165) provided August 3, 2020, to August 16, 2020.
You asked the Plan to pay for the home improvement supplies. You say that you were under the impression you would be reimbursed for this service. The Plan denied your request. The Plan says home improvements are not a covered service.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the home improvement supplies (S5165) provided August 3, 2020, to August 16, 2020.
Your complaint about potentially receiving incorrect information from the Plan's customer service department is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210).

You asked the Plan to pay for the complete series of intraoral x-rays. You say that you would like this claim to be covered. The Plan denied your request. The Plan says this service is not covered by the Plan. The Plan also says that you did not elect to purchase an optional supplemental benefit plan for the 2020 plan year.

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 pay for the complete series of intraoral x-rays (D0210).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous transluminal angioplasty (PTA) procedure.

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 PTA is covered when specific criteria are met.

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 do not support that your symptoms are due to peripheral artery disease. You have a history of arthritis. The walking limitation and pain symptoms are out of proportion to your testing results for peripheral artery disease. The duplex scan does not suggest serious disease in either leg. There is no documentation of your toe pressures. The records do not support that the criteria for the PTA are met; therefore, the services are not medically necessary at this time.

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 a percutaneous transluminal angioplasty (PTA) procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a joystick controller (K0108), an expandable controller upgrade (E2377), a harness (E2313), and an electronic connection between a wheelchair controller and two or more power seating system motors (E2311).
You asked the Plan to pre-approve the joystick controller, the expandable controller upgrade, the harness, and the electronic connection between the wheelchair controller and two or more power seating system motors. You say that the items in dispute are medically necessary and supported by the documentation provided. The Plan denied your request. The Plan says the criteria for coverage of the items that remain in dispute have not been met.
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 joystick controller, the expandable controller upgrade, the harness, and the electronic connection between the wheelchair controller and two or more power seating system motors. Our reviewer says that the items in dispute are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that the power wheelchair accessories at issue in this case are medically reasonable and necessary. Records indicate the enrollee has 3/5 right upper extremity strength which is adequate to control the power options using their own switches.
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 joystick controller, the expandable controller upgrade, the harness, and the electronic connection between the wheelchair controller and two or more power seating system motors have not been met. Therefore, we decided that the Plan does not have to pre-approve a joystick controller (K0108), an expandable controller upgrade (E2377), a harness (E2313), and an electronic connection between a wheelchair controller and two or more power seating system motors (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).

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 you do not meet the criteria for coverage.

The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met. 

We looked at the file and Medicare rules. The file shows that you do not use insulin. 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 a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.

You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of heavily pre-treated prostate cancer, acinar, carcinosarcoma, and ductal cancer. The use of Keytruda in this instance is not supported. There is no documentation of microsatellite instability or a tumor mutational burden of greater than or equal to 10. The Keytruda is therefore 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 Keytruda.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260).
You asked the Plan to pre-approve a semi-electric hospital bed. You say that this service is medically necessary. The Plan denied your request. The Plan says the requested item is not medically necessary and reasonable.
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary when at least one of the following criteria is met: 1. The patient has a medical conditions which requires positioning of the body in ways not feasible with an ordinary bed; or 2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain; or 3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out; or 4. The patient requires traction equipment, which can only be attached to a hospital bed. 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 semi-electric hospital bed. Our reviewer says that the requested item is not medically reasonable and necessary. Our physician reviewer found although you do require positioning of the body in ways not feasible in an ordinary bed, there is no documentation that you require frequent or immediate changes in body positioning as required to authorize coverage for a semi-electric bed.
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 semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Invokana for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Invokana for the enrollee.
Benefits for this 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the reline complete maxillary denture provided on June 2, 2020.
You asked the Plan to pay for the reline complete maxillary denture. You say that this service should be covered under the Optional Supplemental Benefits. The Plan denied your request. The Plan says this service is not covered. The Plan also says that the Optional Supplemental Benefits you enrolled in were not effective until July 1, 2020, which is after this date of 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the reline complete maxillary denture provided on June 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision exam and refraction you received on August 3, 2020.
You asked the Plan to pay for the services. You say that the copayment should be $0. The Plan denied your request. The Plan says you are responsible for the cost share.
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 $35 copayment for outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye.
Review of the file shows that you had a Medicare-covered eye exam and refraction on August 3, 2020. You have been asked to pay a $35 copayment for the eye exam. The exam falls within the vision care benefit category. Additionally, the refraction is not covered as part of a Medicare-covered eye exam. Refractions are only covered under your plan as part of a routine eye exam. 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 pay for the vision exam and refraction you received on August 3, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you disagree with the denial. The Plan denied your request. The Plan says that the admission is not medically necessary.
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 SNF care. Our reviewer says that the admission is medically necessary. Our physician reviewer found the submitted records show that you were admitted to the hospital on March 15, 2021. The physical evaluation states you need maximum assistance with rolling and sitting up. The occupational therapy evaluation states you need assistance with bathing, hygiene, dressing, and toileting. You have no skilled nursing needs. You have skilled therapy needs and are functioning below your baseline level of function. You require skilled therapy on a daily basis. As a practical matter, you require the necessary services on an inpatient basis at the SNF 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
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-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a right total knee replacement. Your medical problems are stable. You do not have complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Additionally, 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 an acute inpatient rehabilitation facility (IRF) admission and 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 the service is medically necessary. The Plan denied your request. The Plan says services can be obtained in a lower level of care.
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 there are no complex nursing or rehabilitation needs and the patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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. Specifically, the enrollee does not required complex nursing or an intensive rehabilitation therapy program. This means the enrollee can obtain medically necessary services at a lower level of care. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral upper eyelid Blepharoplasty, Blepharoptosis
repair (CPT code 67900), for the enrollee.
You asked the Plan to pre-approve the service. You say that the enrollee was diagnosed with dermatochalasis,
ptosis and brow ptosis. The Plan denied your request. The Plan says the clinical record photographs did not
show drooping below the superior orbital rim and do not show significant improvement of the blepharoptosis
and/or dermatochalasis by elevation of the brows as required by Medicare guidelines.
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 service. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found under the controlling LCD, Brow ptosis (performed singly or in combination with other
procedures) must be frontal demonstrating: Drooping of brows below the superior orbital rim; and;
Improvement of blepharoptosis and/or dermatochalasis by elevation of the brows. (Note: If a blepharoplasty
and/or lid ptosis repair and/or brow ptosis are planned, the necessity for each individual procedure performed
and billed to Medicare must be documented and supported by photographs. This may require multiple sets of
photographs (and/or visual fields), showing the effect of drooping of redundant skin (and its correction by
taping or manual retraction) and the actual presence of blepharoptosis and/or brow ptosis and/or an eyelid
dermatitis. In this case, the photographs provided do not demonstrate that the brow extends over the superior
orbital rim. Taping the brow does not demonstrate improvement of the blepharoptosis. Therefore, the elements
of the local coverage determination for the brow lift repair are not satisfied. The brow lift repair cannot be
recommended.
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 service have not been met. Therefore, we decided that the Plan does not
have to pre-approve bilateral upper eyelid Blepharoplasty, Blepharoptosis repair (CPT code 67900), for the
enrollee.