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

 
We decided that the Plan does not have to pre-approve 5mg Eliquis Tablets. 
 
You asked the Plan to pre-approve the Eliquis. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this medication does not fall 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 5mg Eliquis Tablets.  
 
Benefits for the Eliquis 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for myocardial perfusion imaging, tomographic (78452) 
provided September 30, 2020. 
 
You asked the Plan to pay for myocardial perfusion imaging. You say that records attached supporting that this 
procedure was performed by your provider. Claim denied as duplicate in error. Please review and reprocess 
claim for reimbursement according to contract. The Plan denied your request. The Plan says the submitted 
documentation supports 1 unit of 78452-26 which was previously approved/paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
In this case we find that additional units of CPT code 78452-26 are not supported in the medical record. The 
medical record only supports 1 units of CPT code 78452-26. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging have not been met. Therefore, we decided that 
the Plan does not have to pay for myocardial perfusion imaging, tomographic (78452) provided September 30, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthosis of the right knee (L1833) and a suspension sleeve (L2397).

You asked the Plan to pay for a knee orthosis and a suspension sleeve. You say that the enrollee is using this medically necessary item with benefit. The Plan denied your request. The Plan says rules for payment 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 pay for a knee orthosis and a suspension sleeve. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was chronic pain located in the bilateral knees. The documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. There is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.

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 knee orthosis have not been met. Additionally, a suspension sleeve is not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pay for an orthosis of the right knee (L1833) and a suspension sleeve (L2397).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an adjustable queen mattress for the enrollee. 
 
You asked the Plan to pre-approve the mattress. You say that this is not considered durable medical equipment. 
The Plan denied your request. The Plan says the enrollee would benefit from an adjustable mattress that is able 
to be raised and lowered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
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 mattress. Our reviewer says that the 
requested mattress is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested adjustable mattress would not be considered DME as it is not primarily and customarily 
used to serve a medical purpose. It also is useful to a person in the absence of illness or injury. The 
documentation does not reveal extenuating factors or medical condition that would require this queen mattress 
as a medical necessity. 
 
We looked at this physician's review, the file, and Medicare rules. 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. 
 
Based on this information, we decided that Medicare rules for coverage of the mattress have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an adjustable queen mattress for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion pump and supplies (E0781 and A4222) provided 
from April 10, 2020, through April 20, 2020. 
 
You asked the Plan to pay for the infusion pump and supplies. You say that you would like reconsideration 
because this equipment is medically necessary. The Plan denied your request. The Plan says these services are 
inclusive under services approved and paid to the attending oncologist. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT codes E0781 and A4222 are not supported in the record. Specifically, payment for this 
equipment is included in the payment to the attending oncologist. Based on this information, we decided that 
Medicare rules for coverage of the infusion pump and supplies have not been met. Therefore, we decided that 
the Plan does not have to pay for the infusion pump and supplies (E0781 and A4222) provided from April 10, 
2020, through April 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to 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 there is no clinical advantage to the LTACH over the acute hospital. 
 
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 it appears that the enrollee is requiring short term additional acute care services for 
weaning and close monitoring of DVT/PE status and which can be safely be received at the current facility 
until completed. The enrollee does not require services at the LTACH that are not already available at the 
current facility. There are no services at the LTACH that the patient requires that are not already available and 
covered at the current facility. Therefore, this request for LTACH services will be considered not medically 
necessary at this time. Transfer to a lower level of care may be considered soon when treatment 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a patient lift (E0630) provided September 19, 2020. 
 
You asked the Plan to pay for the patient lift. You say that the equipment was medically necessary. The Plan 
denied your request. The Plan says Original Medicare is liable for payment for these items. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a patient lift (E0630) provided September 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary interim partial denture (D5820) provided on 
November 3, 2020. 
 
You asked the Plan to pay for the maxillary interim partial denture. You say that you assumed 50% of this 
service would be covered. The Plan denied your request. The Plan says this service is not a covered benefit 
under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
maxillary interim partial denture (D5820) provided on November 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (personal protective equipment).

You asked the Plan to pay for the personal protective equipment. You say that obtaining preventive dental services should be fully covered. The Plan denied your request. The Plan says this service is 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 preventive procedure (personal protective equipment).
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 stage IV 
A non-small cell lung cancer (NSCLC). The provider notes that Keytruda was previously approved in 
December, and they would like to continue the medication since the enrollee was showing improvement with 
the drug. The recommended Duration/Timing of Treatment of NSCLC with Keytruda is until disease progress, 
unacceptable toxicity, or up to 24 months. The requested use of Keytruda beyond 24 months is not FDA 
approved, nor is it supported in the CMS approved compendia. Continued use of Keytruda is not safe and 
effective or reasonable and 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four gingival irrigations (D4921 x4) provided on October 
28, 2020. 
 
You asked the Plan to pay for the gingival irrigations. You say that you would like these services to be covered. 
The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The 
Plan also says that there was no active dental rider at the time 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 four 
gingival irrigations (D4921 x4) provided on October 28, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable gaseous oxygen system and oxygen concentrator 
provided on June 13, 2020. 
 
You asked the Plan to pay for the portable gaseous oxygen system and oxygen concentrator. You say that these 
services were medically necessary. The Plan denied your request. The Plan says during the hospice election, 
fee-for-service Medicare also covers attending physician services and all care unrelated to the enrollee's 
terminal illness starting on the date of the hospice election until the first day of the month following the month 
in which hospice is revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the portable gaseous oxygen system and oxygen concentrator 
provided on June 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on January 10, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 had network providers 
available who could have provided the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-
network provider on January 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve the total electric hospital bed. You say that you require the bed, that the 
hospital bed will help you. The Plan denied your request. The Plan says your request is not medically necessary 
under the Medicare guidelines as it has features that are considered items of convenience. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for duplex scan of extracranial arteries (93880).

You asked the Plan to waive the copayment for the duplex scan. You say that you received two separate bills for copay's. The Plan denied your request. The Plan says this claim was processed and the correct copayment 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 $40 copayment for Medicare covered x-ray and ultrasounds.

You have been asked to pay $40 copayment for the duplex scan. The duplex scan falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for duplex scan of extracranial arteries (93880).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance transport provided to the enrollee.

You asked the Plan to pay for this transport. You say that transport destination coverage was extended due to Covid-19 and this transport should be covered. The Plan denied your request. The Plan says while destinations were extended by Medicare, enrollees must still meet the required criteria for transport.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for this transport. Our reviewer says that Medicare coverage criteria were not met. Our physician reviewer found the enrollee was at an appointment at an outpatient facility for follow up from a recent hospitalization due to hematuria. Vitals were normal, examination otherwise normal except for noted suprapubic catheter. The documentation does not support that transportation other than an ambulance would be contraindicated for this enrollee. The documentation does not support that the enrollee required expertise and special equipment in the ambulance during transportation as she was stable. Medicare coverage criteria were not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this transport have not been met. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance transport provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker provided to the enrollee on September 23, 2020. 
 
You asked the Plan to pay for the walker. You say that you supplied the DME that the ordering provider 
requested. The Plan denied your request. The Plan says the services were not urgent, emergent, or 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a walker provided to the enrollee on September 
23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the outpatient surgery services provided on 
August 25, 2020, and October 6, 2020. 
 
You asked the Plan to waive the copays for the services provided. You say that you do not agree with the 
copay. The Plan denied your request. The Plan says the services were processed 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 $250 
copay for outpatient surgery.  
 
You have been asked to pay a $250 copay for the services provided on each date of service. The services fall 
within the outpatient surgery 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 copays for the outpatient 
surgery services provided on August 25, 2020, and October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services rendered from September 5, 2020 to 
September 8, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the provider type is not covered. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan's rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the file shows that the services were not rendered by 
a physician licensed to provide acupuncture. Therefore, we decided that the Plan does not have to pay for the 
acupuncture services rendered from September 5, 2020 to September 8, 2020.