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

We decided that the Plan does not have to pre-approve a chest CT scan.
You asked the Plan to pre-approve a chest CT scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested CT scan is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only 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 to pre-approve a chest CT scan. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has been complaining of weight loss and bilateral lower extremities weakness. The enrollee had abdominal and pelvis CT scan that showed lung mass, multiple pulmonary nodules, hepatic and adrenal lesions consistent with metastatic lung malignancy. A full CT chest is not medically necessary as it will not have any additional value to help managing the patient. Therefore, the enrollee does not meet criteria for the requested CT scan. 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 chest CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a chest CT scan.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on March 15, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the service is not allowed because it was 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 pay for the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that in March 2019, the enrollee was being evaluated for metastatic cancer without a known source/primary. Despite a specific diagnosis, the enrollee was started on radiation and chemotherapy. Genetic panel testing was ordered in an apparent attempt to elucidate the source of the cancer. The panel testing was ordered based on a diagnosis of lung cancer, though this had not been established. Assuming the patient did have lung cancer, testing related to lung cancer would have been medically necessary and reasonable. Broad-sweeping panel testing, inclusive of tests which were unrelated to lung cancer or for which no associated therapies were known, was 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on March 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft (CPT D7953), biologic materials (CPT D4265), implant removal (CPT D6100), cone beam computed tomography of both jaws (CPT D0367), local anesthesia (CPT D9215), gingival irrigation (CPT D4921), the surgical placement of an implant body (CPT D6010), and second stage implant surgery (CPT D6011).
You asked the Plan to pre-approve the dental services. You say that you have been in pain for the last 3 months after a post broke off in your gums. The Plan denied your request. The Plan says the services which remain in dispute are non-covered benefits with Medicare and under the enrollee's contract.
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 pre-approve a bone replacement graft (CPT D7953), biologic materials (CPT D4265), implant removal (CPT D6100), cone beam computed tomography of both jaws (CPT D0367), local anesthesia (CPT D9215), gingival irrigation (CPT D4921), the surgical placement of an implant body (CPT D6010), and second stage implant surgery (CPT D6011).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (63012, 63047) provided.
You asked the Plan to pay for surgical services. You say that this should be covered. The Plan denied your request. The Plan says this claim must first be submitted to the enrollee's primary insurance.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has instructed you to submit this claim to the enrollee's primary insurance. As the secondary insurer, the Plan cannot be held responsible for surgical services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for surgical services (63012, 63047) provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the requested item is 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 a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 semi-electric hospital bed. Our reviewer says that the item is not medically necessary. Our physician reviewer found the enrollee's condition does not require positioning of the body in ways not feasible in an ordinary bed. The enrollee does not require frequent or immediate changes in body position. The enrollee does not need special attachments that cannot be fixed and used on an ordinary bed. The semi-electric hospital bed is not medically necessary for this 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 a semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve i-digit access, 2 digit system for the enrollee.
You asked the Plan to pre-approve these services. You say that this should be covered for the enrollee. The Plan denied your request. The Plan says that the information submitted does not meet medical necessity.
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 requested items/services are not considered medically reasonable and necessary in this case. There is insufficient peer-reviewed evidence that examined the clinical value (e.g., improved function and health-related quality of life) of partial-hand or finger myoelectric prostheses. The requested i-digit access device is not furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of this 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve i-digit access, 2 digit system for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. 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 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 enrollee is currently undergoing treatment at an acute care hospital (ACH) for anemia and CoViD-19. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MYO Pro microprocessor upper extremity Orthosis (L8702).
You asked the Plan to pre-approve the orthosis. You say that the enrollee requires the device. The Plan denied your request. The Plan says the MYO Pro microprocessor upper extremity orthosis, is denied as not medically necessary and is considered experimental/investigational because the effectiveness and safety of the requested device is not supported by the referenced medical policy.
The Plan follows Medicare rules. Medicare rules say that it will not cover services that are considered experimental/investigational. 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 orthosis. Our physician reviewer found The MyoPro Orthosis is not medically necessary for the patient per Social Security Act, Section 1862 (a)1(A) and the 42 CFR ?411.15(k). The MyoPro Orthosis is not the most appropriate available supply or level of service for the patient in question considering potential benefits to the patient. It is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this patient, improve her hemiparetic arm function, or be safe for long term
use. There is insufficient evidence in the literature that this device will increase her participation in bimanual activities. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve MYO Pro microprocessor upper extremity Orthosis (L8702)
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services and ED visit provided on June 4, 2019.You asked the Plan to pay forthe laboratory services and ED visit. You say that this claim has not been paid in full or under the terms of the contract for the services provided to this enrollee.The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.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 forthe laboratory services and ED visit provided on June 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9944).
You asked the Plan to pre-approve the occlusal guard. You say that your dentist requested a mouth guard so that you would do no damage to your other crowns. The Plan denied your request. The Plan says this service is not a covered benefit.
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 pre-approve an occlusal guard (D9944).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
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 a therapeutic CGM is 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 enrollee does not meet the criteria for coverage. Our physician reviewer found the enrollee has insulin-treated type II diabetes. The documentation shows she is treated with oral medications and insulin. She does home blood glucose monitoring three times per day. She is not testing the required four or more times per day and does not meet the criteria for coverage of the CGM. The services 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 continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for gym membership annual fee.You asked the Plan to pay for the gym membership. You say that you paid $279.87 for the full year and you are requesting reimbursement of your annual gym fee.The Plan denied your request. The Plan says annual fees are not covered under the plan benefits.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only the plan reimburse you up to $40 per month for qualifying fitness expenses.The Plan's rules for coverage of gym benefits have not been met because The plan does not reimburse for initiation or registration fees, prorated fees, annual fees, account freeze fees, maintenance fees and any miscellaneous fees or other penalties, equipment purchase or rental, any activities that take place in a private residence or private club (including private golf/country clubs), food/supplements, any type of personal/private training or lessons, player's club membership and walking or guided tour activities..Therefore, we decided that the Plan does not have to pay for gym membership annual fee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you fell in your bathroom and could not get back up. You stated that you activated your necklace and the representative told you that they were sending help. You say that two firemen arrived and helped you back up. When you left your bathroom there was two EMT responders in your kitchen waiting to take you to the hospital. You say that you told them you were fine and did not need transportation. You stated that they did not check you or take any of your vitals. You say that you do not feel responsible for the bill because you did not call for the ambulance and they did not do anything for you. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda/Aprepitant/Carboplatin/Docetaxel/Ondansetron for the enrollee.
You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your request. The Plan says this drug regimen is not supported to treat malignant neoplasm of the oropharynx.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drugs. Our reviewer says that the requested drug regimen is not medically reasonable or necessary. Our physician reviewer found the enrollee has advanced/recurrent head and neck cancer that originated in the oropharynx. She is receiving cetuximab with carboplatin and paclitaxel with a limited response. The treating oncologist requests transition to carboplatin/docetaxel and pembrolizumab. This regimen is not a standard of care, which would be carboplatin, 5-FU, and pembrolizumab. Despite prior pembrolizumab the enrollee had response and is more than 6 months from prior use. The combination of carboplatin/docetaxel and pembrolizumab is not supported by the medical literature. The service 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 the drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda/Aprepitant/Carboplatin/Docetaxel/Ondansetron for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy.
You asked the Plan to waive the copayment for the endoscopy. You say that you thought you had the best insurance. You say that you don't know why you have to pay $100. The Plan denied your request. The Plan says the copayment applied 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 $100 per day for outpatient procedures and services, including but not limited to diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center. You have been asked to pay a $100 copayment for the endoscopy. The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the endoscopy was performed. 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 endoscopy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Lorazepam, Transderm-Scop, Phenazopyridine, Ondansetron (Zofran), Levothyroxine Sodium, Oxycodone, Bupropion, and Miralax provided.
You asked the Plan to pay for the Lorazepam, Transderm-Scop, Phenazopyridine, Ondansetron (Zofran), Levothyroxine Sodium, Oxycodone, Bupropion, and Miralax. The Plan denied your request. The Plan says you were given self-administered drugs while you were treated in a hospital outpatient setting, which are not covered by 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 pay for the Lorazepam, Transderm-Scop, Phenazopyridine, Ondansetron (Zofran), Levothyroxine Sodium, Oxycodone, Bupropion, and Miralax provided.
Benefits for the Lorazepam, Transderm-Scop, Phenazopyridine, Ondansetron (Zofran), Levothyroxine Sodium, Oxycodone, Bupropion, and Miralax may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.