Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission a long-term acute care hospital (LTACH) for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is not medically stable for discharge from the acute inpatient hospital setting.

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 the short-term acute care hospital can provide for all of the enrollee's present inpatient care needs and the enrollee is receiving an appropriate level of care in the present setting. The plan has stated that continued care in the short-term acute care hospital will be covered. Continued care in the short-term acute care hospital is appropriate until the enrollee is weaned off the Neosynephrin and is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing facility.

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 admission a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an air purifier (E1399).
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this item is not a covered benefit under your contractual policy.
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 pre-approve an air purifier (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on November 25, 2020.

You asked the Plan to waive the copayment for a specialist visit. You say that the visit was a follow-up to a surgical procedure and you should not owe a copayment. 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 $30 copayment for specialist services.

You had a specialist visit on November 25, 2020, as a follow-up to a surgical procedure. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $30 copayment.

You have been asked to pay a $30 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 specialist visit provided on November 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a reclining chair.
You asked the Plan to pre-approve the chair. You say that you would like to be able to sit and stretch your legs. The Plan denied your request. The Plan says this is not a covered benefit.
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 pre-approve a reclining chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 4, 2020, and November 11, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the services at issue. 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 physician's services provided on November 4, 2020, and November 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a humidifier (E0560).
You asked the Plan to pre-approve a Humidifier. You say that you have sleep apnea, trouble breathing and asthma. You need the machine will help you breathe better. The Plan denied your request. The Plan says this device is considered to be environmental control equipment and not primarily medical in nature.
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 pre-approve a humidifier (E0560).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no long-term peer reviewed studies on the benefit of the Vertiflex device for the treatment of lumbar spinal stenosis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral sacroiliac joint radiofrequency ablation.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this treatment has not been shown to provide a clear long-term benefit over standard treatment for chronic sacroiliac joint pain.

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 this is considered an experimental/ investigational procedure because of the wide variation in efficacy in the peer reviewed literature. Therefore, it is considered 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral sacroiliac joint radiofrequency ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain crown (D2740) provided on October 22, 2020.
You asked the Plan to pay for the dental service. You say that a plan representative advised that crowns were covered. You say that you did not know that crowns were not covered in 2020, as they were covered in 2019 and 2021. You also say that if you had known that the crown would not be covered, you would have put it off until 2021. The Plan denied your request. The Plan says porcelain crown is not listed as a covered service. The Plan also says that any services not listed are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the porcelain crown (D2740) provided on October 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit (99203) provided January 7, 2021.
You asked the Plan to waive the copayment for the telehealth visit. You say that you called to speak to your doctor and this was not the doctor you wanted. The visit was a waste of your time and you do not accept that you have to pay the office copay as they did nothing. The Plan denied your request. The Plan says the claim was processed and the correct copay was applied per the Evidence of Coverage.
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 $15 copay for each covered telehealth visit or consultation in an outpatient location with a specialist. You have been asked to pay $15 copay for the telehealth. the telehealth falls within the Physician/Practitioner services, including doctor's office visits 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 telehealth visit (99203) provided January 7, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve IUD placement for the enrollee.

You asked the Plan to pre-approve the placement. You say that this is medically necessary, as it was not placed for contraceptive purposes. The Plan denied your request. The Plan says that this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 placement. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the Levonorgestrel IUD is a safe, effective, FDA-approved treatment for heavy menstrual bleeding. In this case, it is not being used as a contraceptive but as a treatment for abnormal uterine bleeding which is standard of care in the field of gynecology. This is reasonable and necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the placement have been met. Therefore, we decided that the Plan has to pre-approve IUD placement 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing (0012M) provided on October 16, 2020.

You asked the Plan to pay for CxBladder testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are non-covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that the Plan does not have to pay for CxBladder testing (0012M) provided on October 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).

You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

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 Prolia. Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee. Our physician reviewer found based on the medical records provided the enrollee has not tried and failed the required drug, Zoledronic acid. Our reviewer also found that there is no indication that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox (J0585).
You asked the Plan to pre-approve Botox. The Plan denied your request. The Plan says this medication does not fall under Part B.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Botox (J0585).
Benefits for Botox 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: Partially Favorable

We decided that the Plan has to pre-approve E2311, E2313, E2377. We decided that the Plan does not have to pre-approve E2300 and K0108.
You asked the Plan to pre-approve the various accessories. You say that this is medically necessary. The Plan says that this is not medically necessary.
We decided that the Plan has to pre-approve E2311, E2313, and E2377.
The Plan follows Medicare rules. Medicare rules say that services are covered when they are medically 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 for E2311, E2313, and E2377. Our reviewer says that the requested accessories are medically reasonable and necessary. Our physician reviewer found that the enrollee is dependent on the wheelchair for mobility. She is independent with self-care tasks using the power wheelchair. There is a history of multiple pressure injuries to the sacrum and coccyx, and she relies on the power tilt and power recline to offload pressure and prevent injuries. The documentation supports that these accessories are medically reasonable and necessary and are needed to prevent injury and illness. These are appropriate to the enrollee's medical needs and condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of E2311, E2313, E2377 have been met. Therefore, we decided that the Plan has to pre-approve E2311, E2313, and E2377.
We also decided that the Plan does not have to pre-approve E2300 and K0108.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The items at issue - E2300 and K0108 - do not serve a purpose that is primarily medical in nature. Based on this information, we decided that Medicare rules for coverage of E2300 and K0108 have not been met. Therefore, we decided that the Plan does not have to pre-approve E2300 and K0108.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis Emu.

You asked the Plan to pre-approve Restasis Emu. You say that the enrollee has been on Restasis continuously for the last 6 months, and there has been an improvement in the enrollee's symptoms. The Plan denied your request. The Plan says this medication does not fall 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 Restasis Emu.

Benefits for Restasis Emu 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 therapeutic continuous glucose monitor provided November 11, 2020.

You asked the Plan to pay for the therapeutic continuous glucose monitor. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says the requirements for the durable medical equipment have not been met.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain valid medical records which support medical necessity for the supplies provided in this case. In this case, the medical records do not demonstrate that the prescribing physician has discussed the need for the continuous glucose monitor with the enrollee during an examination. The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided November 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral hygiene instructions (D1330) provided on August 27, 2020.
You asked the Plan to pay for the dental service. You say that you had an appointment for an exam, x-ray, and a cleaning. You say that no one advised there were services provided that would not be covered. You say that The Plan denied your request. The Plan says oral hygiene instruction is 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, 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 oral hygiene instructions (D1330) provided on August 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced knee/foot feature and prosthetic leg covering (L5828, L5845, L5848, L5856).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found an individual who is considered a level 3 ambulator has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. In this case, the enrollee requires the use of an assistive device for ambulation. The documentation supports that she is not a level 3 ambulator. The specialized prosthesis is not 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a prosthetic leg with an advanced knee/foot feature and prosthetic leg covering (L5828, L5845, L5848, L5856).