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

We decided that the Plan does not have to pay for the progressive lenses (V2781) and scratch resistant coating (V2760) provided January 7, 2021.
You asked the Plan to pay for the progressive lens and scratch resistant coating lens upgrades. You say that you thought the glasses would be covered in full. The Plan denied your request. The Plan says the standard frames and lenses have been covered by the Plan, but the lens upgrades are not covered.
Medicare covers standard frames and lenses after cataract surgery. Lens upgrades are not covered. We looked at the file and the Plan's rules. Though Medicare covers standard frames and lenses after cataract surgery, the lens upgrades are not a covered item.. Therefore, we decided that the Plan does not have to pay for the progressive lenses (V2781) and scratch resistant coating (V2760) provided January 7, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says per Medicare Hospice rules the diagnosis is no longer considered and you elect to discontinue the federal Medicare Hospice program and choose to leave hospice care, their Medicare Advantage Plan won't start again until the first of the following month which in this case would be August 1, 2021.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on July 8, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. 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 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. At the time of the request, the enrollee's status is unstable. The enrollee still has low-grade fevers, persistent leukocytosis, underlying sepsis, and intermittent episode of atrial fibrillation (AFib) with rapid ventricular response (RVR). There is also concern for a CSF leak, per the provider notes dated July 20, 2021. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care.
There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the oral exam. We decided that the Plan does not have to pay for the
periodontal maintenance.
You asked the Plan to pay for these services. You say that this should be covered. The Plan says that these
services are not covered by the Plan.
We decided that the Plan has to pay for the oral exam.
The Plan follows Medicare rules. Medicare rules say that dental services are not covered but this Plan has a
supplemental benefit that includes an allowance that can be used toward oral exams
In this case, no evidence was provided that the $250 allowance was exhausted as of this date of service. There
was no compelling argument provided to support non-payment of this service. Therefore, we decided that the
Plan has to pay for the oral exam.
We also decided that the Plan does not have to pay for the periodontal maintenance.
As noted above, the Plan has a supplemental dental benefit; however, this does not provide coverage for
periodontal maintenance. Therefore, we decided that the Plan does not have to pay for the periodontal
maintenance.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral to an ophthalmologist.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says medically necessary care is available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral to an ophthalmologist.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the professional component of the laboratory testing provided on January 15, 2021, reported with modifier -26.
You asked the Plan to pay for the professional component of the laboratory services rendered. You say that denial of these claims is a violation of Florida law and your contract with the Plan. These are medically necessary services that must be reimbursed. The Plan denied your request. The Plan says these services are not appropriately billed with modifier -26.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The CPT codes at issue in this case are not payable on the Physician Fee Schedule as they are statutorily excluded. Though these can be paid on the Clinical Laboratory Fee Schedule, the codes are not payable as such with modifier -26.
Payment for the global (professional and technical components) service of the lab testing is made to the
rendering laboratory only. Based on this information, we decided that Medicare rules for coverage of the
professional component of the laboratory services rendered have not been met. Therefore, we decided that the
Plan does not have to pay for the professional component of the laboratory testing provided on January 15,
2021, reported with modifier -26
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation trips.
You asked the Plan to provide additional transportation. You say that this transportation is necessary for you to get to your dialysis appointments. You do not have other reliable transportation. The Plan denied your request. The Plan says the Plan can cover up to 48 routine transportation trips. Additional trips are not covered under this supplemental benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the requested transportation exceeds the Plan's maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide additional routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay from November 24 through November 26, 2020.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that medical surgical supplies were listed on the hospital bill, but you did not receive surgery. You do not want to pay for services you did not receive. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $200 copayment per day for days 1 to 10 for Inpatient Hospital Services. You have been asked to pay $600 in copayments (a $200 copayment per day for days 1 to 3) for the inpatient hospital stay. The inpatient hospital stay falls within the Inpatient Hospital 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 copayment for the inpatient hospital stay from November 24 through November 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot, ankle feature,
and other parts.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says a request for a K3 foot does not meet the Medicare criteria as reasonable and 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 services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found these requested items exceed your medical needs. The medical progress notes from the treating
nurse practitioner do not support that you are at an ambulation of K3 or above.
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 a prosthetic leg with an advanced foot, ankle feature, and other parts
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular testing provided on January 13, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that coverage for all CV risk assessment panels, except the basic lipid panel, is denied for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease.
We looked at the file and Medicare rules. Per LCD L36358, the requested cardiovascular testing is not covered. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular testing provided on January 13, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Bavencio/Avelumab for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this request does not meet the requirements.
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 the drug. Our reviewer says that the requested drug is medically reasonable and necessary. Our physician reviewer found Avelumab is FDA approved for the first-line maintenance treatment of locally advanced or metastatic urothelial carcinoma that has not progressed with first-line platinum-containing chemotherapy. Metastatic collecting duct cancers are treated as urothelial cancer. This enrollee had cisplatin and gemcitabine. The service is reasonable and medically necessary and safe and effective. 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 drug have been met. Therefore, we decided that the Plan has to pre-approve Bavencio/Avelumab for the enrollee.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Praluent injection, 75 mg/ml.
You asked the Plan to pre-approve the Praluent injection. You say that the enrollee has tried medications similar to Praluent with no success. You also say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested 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 a Praluent injection, 75
mg/ml.
Benefits for the Praluent injection 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 spinal column stimulation trial for the enrollee to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there are network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve spinal column stimulation trial for the enrollee to be provided by an out of network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intermittent limb compression device (E0651).
You asked the Plan to pre-approve an intermittent limb compression device. You say that this device is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. 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 intermittent limb compression device. Our reviewer says that the requested device is not medically necessary. Our physician reviewer found the documentation does not reveal clear evidence of a diagnosis of true lymphedema and marked hyperkeratosis with hyperplasia and hyperpigmentation, papillomatosis cutis lymphostatica, deformity of elephantiasis, skin breakdown with persisting lymphorrhea, and detailed measurements over time confirming the persistence of the lymphedema with a history evidencing a likely etiology. There is no evidence of an adequate 4 week trial of conservative therapy which must include detailed measurements, obtained in the same manner and with reference to the same anatomic landmarks, prior to and at the conclusion of the various trials and therapy, with bilateral comparisons where appropriate. 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 intermittent limb compression device have not been met. Therefore, we decided that the Plan does not have to pre-approve an intermittent limb compression device (E0651).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint ablation.
You asked the Plan to pre-approve the services. You say that you have had longstanding lower left back pain. The Plan denied your request. The Plan says there has only been one diagnostic injection.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Medicare guidelines require two sets of diagnostic medial branch blocks. Only one set has been completed.
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 facet joint ablation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that there is no advantage in moving the member from the current
acute care hospital to an LTACH.
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. 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 he is currently receiving care. Our physician
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.
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 for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve portable oxygen concentrator. You say that you are appealing this denial.
The Plan denied your request. The Plan says the denial of authorization for this item is correct, because you do
not meet the Medicare coverage criteria.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify
for oxygen solely based on blood gas studies obtained during sleep.
To qualify for home oxygen, the patient must meet one of the following blood gas levels:
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during
sleep for a patient who have hypoxia symptoms during sleep;
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for
patients who have hypoxia symptoms during exercise;
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of
dependent edema, pulmonary hypertension, or erythrocythemia.
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air,
there is a rebuttable presumption of non-coverage.
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 portable oxygen concentrator. Our
reviewer says that you do not meet the Medicare criteria for a portable oxygen concentrator. Our physician
reviewer found you began using oxygen after a motor vehicle crash and have sleep apnea. You have a resting
oxygen saturation at 98%. Therefore, you do not meet the coverage criteria and this device 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 portable oxygen concentrator have not been met. Therefore, we decided that the
Plan does not have to pre-approve a portable oxygen concentrator.