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

We decided that the Plan does not have to pre-approve a fluid, pneumatic, or electronic/microprocessor knee; flex feature; swing & stance phase; and axial ankle with swing phase for prosthesis.

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 K3 level prosthetic accessories are 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 enrollee has a history of left above knee amputation six years prior. The records do not support that the enrollee is a K3 ambulator. He ambulates with a cane and has frequent falls, which is not consistent with a K3 level. The requested accessories are 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 a fluid, pneumatic, or electronic/microprocessor knee; flex feature; swing & stance phase; and axial ankle with swing phase for prosthesis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compressor to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a pneumatic compressor. You say that you would like these services approved. The Plan denied your request. The Plan says there are in-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 a pneumatic compressor 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 the MyoPro Motion G Orthotic device (CPT code L8702), for the enrollee.
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your request. The Plan says peer reviewed literature considers the use of robotic therapy for upper and lower extremity stroke rehabilitation investigational in nature and does not support its use since there is no long-term outcome data or continuation rate data at this time.
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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro orthosis is considered experimental, investigational and unproven when used to help restore function to arms and hands paralyzed or weakened by cerebrovascular accident (CVA) stroke, brachial plexus injury, cerebral palsy or any other neurological or neuromuscular disease or injury. There is insufficient literature in the peer reviewed publications to assess safety, efficacy, long term outcomes or patient management associated with the use of the MyoPro Orthosis for upper extremity paralysis/paresis. The review has determined that the items/services at issue in this case are not medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G Orthotic device (CPT code L8702), for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on March 28, 2021.

You asked the Plan to waive the copayment for emergency care. You say that you had two emergency room visits in a short time period and already paid one $90 copayment and request that the second copayment be waived. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 $90 copayment for emergency care. 

You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency care 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 emergency care provided on March 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ramucirumab to be used with paclitaxel.

You asked the Plan to pre-approve ramucirumab to be used with paclitaxel. You say that the requested ramucirumab to be used with paclitaxel to treat squamous cell metastatic NSCLC is medically necessary. The Plan denied your request. The Plan says the requested ramucirumab to be used with paclitaxel to treat squamous cell metastatic NSCLC 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 ramucirumab to be used with paclitaxel. Our reviewer says that the requested ramucirumab to be used with paclitaxel to treat squamous cell metastatic non-small cell lung cancer (NSCLC) is not medically necessary. Our physician reviewer found the record indicates that the enrollee has metastatic squamous cell carcinoma of the lung. The treatment is requested as salvage therapy after failure of third line therapy. The Food and Drug Administration has not approved the requested regimen for the enrollee's condition.

The Medicare approved cancer compendia do not contain a class 1 or 2A recommendation in support of the requested treatment. No literature from Medicare approved cancer compendia was submitted for review. The elements of the coverage criteria are not satisfied. The requested service is not 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 ramucirumab to be used with paclitaxel have not been met. Therefore, we decided that the Plan does not have to pre-approve ramucirumab to be used with paclitaxel.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve melanoma screening testing.
You asked the Plan to pre-approve genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says this testing has not passed the MolDX process for clinical validity and utility and is being ordered as screening.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, genetic testing, is being requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pre-approve melanoma screening testing
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer device.
You asked the Plan to pre-approve the Superion procedure. You say that it is felt that this would be the most appropriate treatment for the enrollee. The Plan denied your request. The Plan says this spacer device is not shown to be clinically superior to standard treatments.
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 Superion procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Superion spacer is experimental. More research is needed to show safety and efficacy of the device. 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 Superion procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the positron emission tomography (PET) scan you had on March 12, 2021.
You asked the Plan to waive the copayment for the PET scan. You say that you would like this amount adjusted. The Plan denied your request. The Plan says 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 $300 copayment for diagnostic radiology (other than CT scans). You have been asked to pay a $300 copayment for the PET scan. The PET scan falls within the diagnostic radiology (other than CT scans) 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 positron emission tomography (PET) scan you had on March 12, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require any skilled nursing services and you do not require skilled therapy on a daily basis at an inpatient level in a SNF. 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 SNF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2751) for tooth #6 and #28, endodontic therapy (D3310) for tooth #6, and the upper and lower partial denture (D5213 and D5214).
You asked the Plan to pre-approve a crown (D2751) for tooth #6 and #28, endodontic therapy (D3310) for tooth #6, and the upper and lower partial denture (D5213 and D5214). You say that you have difficulties eating due to damaged teeth and you are in pain. The Plan denied your request. The Plan says your benefits were exhausted for the crown for tooth #28 and the partial dentures. The Plan also says that the crown and endodontic therapy for tooth #6 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 a crown (D2751) for tooth #6 and #28, endodontic therapy (D3310) for tooth #6, and the upper and lower partial denture (D5213 and D5214) 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 a crown (D2751) and endodontic therapy (D3310) for tooth #6. Our reviewer says that the documentation provided does not support the need for a root canal and crown restoration for tooth #6. Our physician reviewer says the dental record and radiographs did not reveal any pathology associated with tooth #6. The tooth appears intact with no significant coronal breakdown due to caries or fracture
The crown for tooth #28 is not a covered benefit. A crown is only covered once per tooth every five years. The Plan paid for a crown for tooth #28 provided on August 22, 2018, which exhausted your benefit. The upper and lower partial dentures (D5213 and D5214) are not covered benefits. Partial dentures are only covered once every 5 years. The Plan paid for an upper and lower partial denture provided on October 3, 2018, which exhausted your benefit. 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 a crown (D2751) for tooth #6 and #28, endodontic therapy (D3310) for tooth #6, and the upper and lower partial denture (D5213 and D5214) have not been met. Therefore, we decided that the Plan does not have to pre-approve the crowns (D2751), endodontic therapy (D3310), and the upper and lower partial denture (D5213 and D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a vascular surgeon on May 3, 2021.

You asked the Plan to waive the copayment for the specialty office visit. You say that you do not feel you should have to pay this copayment because you had a test that showed you had peripheral artery disease, but this doctor said you did not. The Plan denied your request. The Plan says 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 $45 copayment for visits with a specialist. 

You have been asked to pay a $45 copayment for the specialty office visit. This copayment applies regardless of the reason for the visit. 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 office visit you had with a vascular surgeon on May 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic office visit you had on January 28, 2021.

You asked the Plan to pay for the visit. You say that you thought the visit would be covered. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Office visits are not covered under the chiropractic benefit. Therefore, we decided that the Plan does not have to pay for the chiropractic office visit you had on January 28, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 13 home health physical therapy visits.

You asked the Plan to pre-approve 13 home health physical therapy visits. You say that the requested home health care is medically necessary. The Plan denied your request. The Plan says the criteria for home health physical therapy visits have not been met.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 13 home health physical therapy visits. Our reviewer says that the requested home health services are not medically reasonable and necessary. Our physician reviewer found based on the documentation provided, the enrollee does not have documented skilled therapy needs. In addition, the enrollee is functioning at a level commiserate with a lower level of care. As such, the requested, ongoing, home health physical therapy services are not medically necessary or reasonable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 13 home health physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 13 home health physical therapy visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve occupational therapy to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve the occupational therapy. The Plan denied your request. The Plan says you do not have an out-of-network benefit. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), and cases in which the Plan authorizes use of out-of-network providers.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve occupational therapy to be provided by the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the hand-finger orthoses you received on February 26, 2021.

You asked the Plan to waive the coinsurance for the hand-finger orthoses. You say that you should not have any copayment under your plan. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for prothetic or orthotic devices. 

You have been asked to pay 20% coinsurance for the hand-finger orthoses. The hand-finger orthoses fall within the prothetic or orthotic devices 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 for the hand-finger orthoses you received on February 26, 2021.
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 these services are medically necessary. The Plan denied your request. The Plan says that the documentation received fails to indicate you require a multidisciplinary approach with specialized therapies, specialty rehab nursing, and physician oversight.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
You were admitted for an ankle fracture after a fall and were transferred to skilled nursing from June 1, 2021 through June 24, 2021. You have since been living in a long term care facility with ongoing weakness. Your medical problems are stable. There are no 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 documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation 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 an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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-approve acute inpatient rehabilitation facility (IRF) admission and services.