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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found based on the medical records provided daily
skilled services are not required. This enrollee does not require the services on an inpatient basis, in a skilled
nursing facility setting. Services in the home or an assisted living facility with home health services or in a
long-term care facility on a part time basis appear appropriate in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services you received from August 7, 2020, to August 14, 2020.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you thought you were enrolled in a plan that didn't have a copayment for hospital stays. 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 $275 copayment per day for days 1-7 for inpatient hospital care. You have been asked to pay a $275 copayment per day for days 1-7 for the inpatient hospital services. 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 services you received from August 7, 2020, to August 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve these services. You say that the inserts will reduce your left foot pain. The Plan denied your request. The Plan says the services are not covered.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pain management services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve pain management services. You say that you would like approval for these
services. 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
pain management services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the prostate surgery provided on August 4, 2020.
You asked the Plan to waive the copayment for the prostate surgery. You say that you cannot afford to pay the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $200 copayment for surgery services at an in-network ambulatory surgical center. You have been asked to pay a $200 copayment for the prostate surgery. The prostate surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 prostate surgery provided on August 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an artificial cervical discectomy (ACD).
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 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has complaints of severe
left-sided neck pain radiating into the upper extremity. There is reported imaging evidence of a normal disc at
C6/7 with moderate facet disease and no foraminal stenosis. She has reportedly failed conservative treatment,
including activity modification, medications, physical therapy, and epidural steroid injection. There is no
documentation of a comprehensive neurologic exam or actual imaging report to establish the medical necessity
of surgical intervention. Additionally, there is no documentation to support the medical necessity of artificial
disc replacement adjacent to prior fusion over standard anterior cervical discectomy and fusion. In this case, the
requested cervical artificial disc replacement at C6/7 would not be considered the standard of care or medically
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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve an artificial cervical discectomy (ACD).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system, cup holder, and phone
holder for a power wheelchair (PWC).
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 covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The services at issue are a power seat elevation system, a cup holder, and a phone holder. These items do not
serve a purpose that is primarily medical in nature and are not covered by Medicare. Therefore, we decided that
the Plan does not have to pre-approve a power seat elevation system, cup holder, and phone holder for a power
wheelchair (PWC).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass lenses purchased on July 27, 2020.
You asked the Plan to pay for eyeglass lenses. You say that you should be reimbursed since you followed the Plan guidelines. The Plan denied your request. The Plan says rules for payment have not been met.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers $200 toward the purchase and fitting of eyeglasses and lenses at a network optical provider once per calendar year. We looked at the file and the Plan's rules. The record shows that the Plan has applied the full $200 annual benefit, plus a 20% discount, to your purchase. You are responsible for any amount over the Plan contribution. Based on this information, we decided that the Plan's rules for coverage of eyeglass lenses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass lenses purchased on July 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the FreeStyle Libre CGM.
You asked the Plan to pre-approve the CGM. You say that you would like reconsideration because the member
meets coverage criteria. The Plan denied your request. The Plan says there is no evidence that the member
receives at least three injections per day or that the member is testing regularly.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood
glucose testing at least four times per day or use insulin with at least three daily injections. Based on this
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we
decided that the Plan does not have to pre-approve the FreeStyle Libre CGM.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac joint injection procedure for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied
your request. The Plan says there is no indication of a trial and failure of a six week course of physical therapy.
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 procedure. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found in this case, the enrollee has only received medical therapy. The physical examination does not
detail specifics regarding pain in the sacroiliac joint. The review has determined that the requested SIJ injection
is 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 procedure have not been met. Therefore, we decided that the Plan does not
have to pre-approve a sacroiliac joint injection procedure for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a dental office visit (D9430) on August 11, 2020.
You asked the Plan to pay for a dental office visit. You say that the Plan must discard its wrongful decision.
The Plan denied your request. The Plan says rules for payment have not been met.
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 dental office
visit only when obtained from a contracted dental provider.
We looked at the case file and Medicare rules. The provider is not contracted with your Plan. Based on this
information, we decided that the Plan's rules for coverage of a dental office visit have not been met. Therefore,
we decided that the Plan does not have to pay for a dental office visit (D9430) on August 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a therapeutic continuous glucose monitor (CGM).
You asked the Plan to preapprove the CGM. You say that the claim should be paid as the beneficiary does test
frequently. The Plan denied your request. The Plan says there is no documentation of blood insulin injections
there or more times a day and frequent adjustments of insulin based on glucose readings.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM
have not been met. Therefore, we decided that the Plan does not have to preapprove a therapeutic continuous
glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT).
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 HBOT is covered for specific indications only.
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 enrollee does not have a condition for which HBOT is covered. Our physician reviewer found the enrollee
has a diagnosis of Type 2 diabetes with a foot ulcer. On October 13, 2020, a bone scan was consistent with
osteomyelitis in the right proximal fifth metatarsal. On November 20, 2020, it is documented that enrollee's
right midfoot wound "continues to heal with contracting size and margin." There was no surrounding erythema, significant tenderness, malodor or purulence. The foot ulcer on the left lateral heel was completely
epithelialized with no residual wound. There was no surrounding erythema or drainage. While the enrollee has
diabetic wounds of the right and left lower extremities, the documentation does not support that the enrollee
has failed an adequate course of standard therapy, as there were measurable signs of healing. The HBOT is 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 hyperbaric oxygen therapy (HBOT).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six skilled nursing visits.
You asked the Plan to pre-approve six skilled nursing visits. You say that the services are necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria has 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 six skilled nursing visits. Our reviewer
says that the services are not medically necessary. Our physician reviewer found in this case, the
documentation doesn't support that you require skilled nursing services to provide treatment that is medically
necessary. You do not require skilled nursing to effectively provide treatment, care, and/or services in order to
improve your condition, perform a maintenance program to maintain your condition and/or prevent
deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or
hospitalizations.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of six skilled nursing visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve six skilled nursing visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and coinsurance for the lab services you had at an out-of-network hospital on August 11, 2020.
You asked the Plan to waive the deductible and coinsurance for the lab services. You say that your doctor ordered lab services for you, but your Plan didn't pay very much towards this. 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 a $500 deductible for out-of-network care, as well as 50% coinsurance for lab services at an out-of-network hospital facility. You have been asked to pay a $500 deductible as well as 50% coinsurance for the lab services. You received these services at an out-of-network outpatient hospital. You had not yet met your deductible when you received these services. 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 deductible and coinsurance for the lab services you had at an out-of-network hospital on August 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 19, 2019.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in a skilled nursing facility and should have been billed with POS code 32. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove the power recline features for the power wheelchair
(E2311, E2377, E2313).
You asked the Plan to preapprove power recline. You say that the enrollee requires these features. The Plan
denied your request. The Plan says the requested codes (E2311, E2377, E2313) exceed the member's needs and
cannot be covered.
The notes state that these are needed when 3 or more actuators are being used. The electrical connection
between the wheelchair controller and two or more motors (E2311), expandable controller(E2377) and harness
(E2313) cannot be covered. Although there are three approved power options on this wheelchair (tilt, recline
and elevating leg rests), there is not a medical need to control these power options through the joystick. Member's upper limb strength and function are therefore adequate for the member to be able to control the
power options using their own switches which are included in the allowance of these power options.
Therefore, we decided that the Plan does not have to preapprove the power recline features for the power
wheelchair (E2311, E2377, E2313).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve selective internal radiation treatment (SIRT).
You asked the Plan to pre-approve SIRT. You say that the services are necessary. The Plan denied your
request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not
been met.
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 SIRT. Our reviewer says that the
requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found Y-90 microspheres/radioembolization is medically necessary for non-colorectal cancer liver
metastases when other acceptable standard therapies are unlikely to be effective (i.e. chemotherapy) and/or the
enrollee's disease has progressed on standard therapy (as the case with this enrollee). This reviewer does not
believe that radioembolization would be appropriate and "furnished in accordance with accepted standards of
medical practice".
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SIRT have been met. Therefore, we decided that the Plan has to pre-approve
selective internal radiation treatment (SIRT).
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.