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

We decided that the Plan does not have to pre-approve the requested drug for the enrollee.
You asked the Plan to pre-approve self-administered drugs. You say that this drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered 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 drug requested here is not covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the requested drug for the enrollee.
Benefits for self-administered drugs 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra eye drops for the enrollee.
You asked the Plan to pre-approve Xiidra. You say that other options have failed. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered drugs.
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 Xiidra eye drops for the enrollee.
Benefits for Xiidra 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 7, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 physician's services. 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 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings.
You asked the Plan to pre-approve the compression stockings. You say that the compression stockings are a major part of your treatment for lymphedema. The Plan denied your request. The Plan says you have no open venous stasis ulcers, and no wounds on her lower extremities.
The Plan must follow Medicare rules. Medicare rules say that compression stockings are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee has dementia, a history of falling, and a recent diagnosis of COVID19. You say that the enrollee would benefit from additional physical therapy. The Plan denied your request. The Plan says the enrollee has completed her skilled goals and is medically stable with no daily skilled needs.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records do not show that ongoing skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessary for the enrollee in a SNF beyond what was approved by the health plan after the last covered day. There are no complex wounds, IV medications, new enteral feedings or other skilled nursing need after the last covered day. The enrollee's functional level does not require ongoing skilled therapy services in a SNF to effectively provide treatment, care, and/or services which are medically necessary for the enrollee beyond what was approved by the health plan after the last covered day. It is not medically reasonable and necessary to provide these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 27365) provided on September 28, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 27365 is "Radical resection of tumor, femur or knee". We asked our coding 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 use of CPT code 27365 is not supported by the records provided. Our coding reviewer found that the medical records provided do not include documentation of "Radical resection of tumor, femur or knee" being performed on September 28, 2019, therefore this service cannot be validated. The required description for this procedure is not documented in the operative note provided. We looked at this coder'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 the services (CPT 27365) provided on September 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the seat lift mechanism of the power lift recliner purchased on August 28, 2019.
You asked the Plan to reimburse you for the power lift recliner. You say that the lift chair has helped you tremendously. The Plan denied your request. The Plan says the supplier is not a Medicare certified retailer therefore no payment can be made.
The plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. The item at issue in this appeal was provided by a provider not certified by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the seat lift mechanism of the power lift recliner purchased on August 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a specialist physician on November 25, 2019.
You asked the Plan to waive the copayment for a specialist office visit. You say that this is a follow-up appointment. You say that you should not have a copayment for this. The Plan denied your request. The Plan says The correct copayment has been applied.
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 physician/practitioner services/specialist visit. You have been asked to pay a $30 copayment for a specialist office visit. Follow-up office visits are still subject to cost-sharing; therefore, the correct copayment has been applied. A specialist office visit falls within the physician/practitioner services/specialist visit 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 office visit provided by a specialist physician on November 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standing frame and related accessories.
You asked the Plan to pre-approve a standing frame. You say that the standing frame can slow the decline in joint and muscle tissue. The Plan denied your request. The Plan says a standing frame is not used for a medical need.
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. Therefore, we decided that the Plan does not have to pre-approve a standing frame and related accessories.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services received on August 20, 2016.
You asked the Plan to pay for the emergency room services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the claim was not submitted within the required 12 month timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the emergency room services was not filed until August 9, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the emergency room services received on August 20, 2016.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, there are no identifiable daily skilled nursing or daily skilled therapy services required by the enrollee. This enrollee's condition does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional physical therapy visits, for a total of 12 visits.
You asked the Plan to pre-approve additional physical therapy. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has moderate persistent myelopathy. The enrollee has had extensive prior therapy visits and the recent documentation does not reveal evidence of significant objective functional improvement from this therapy. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide ongoing treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The enrollee has been instructed in a home exercise program. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional physical therapy visits, for a total of 12 visits.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing home health services.
You asked the Plan to pre-approve continued home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
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 continued home health services. Our reviewer says that the documentation does not support that the requested home health services are medically reasonable or necessary. Our physician reviewer found the enrollee has had no falls, all wounds are healed, and skin intact. The records do not show that skilled nursing home services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. The documentation does not reveal evidence of complex wound care, IV medications, enteral feedings or other skilled nursing need. The enrollee's wounds are healed and she has been educated on their condition. Therefore, the enrollee does not meet criteria for the requested services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing home health services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fasenra for the enrollee.
You asked the Plan to pre-approve Fasenra. You say that the enrollee has failed other drugs. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered drugs.
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 Fasenra for the enrollee.
Benefits for Fasenra 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 8, 2019 by an out of network (OON) provider.
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 services were rendered by an out-of-network provider without 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 has network providers available who can provide 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 the medical services provided on August 8, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mastectomy for gynecomastia (19300).
You asked the Plan to pre-approve a mastectomy for gynecomastia. You say that you need this due to your excess skin. The Plan denied your request. The Plan says this is cosmetic.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. 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 mastectomy for gynecomastia. Our reviewer says that the requested service is cosmetic in nature and is not medically necessary. Our reviewer found you have a relatively mild condition of gynecomastia (Grade I documented) without evidence of functional impairment. The treating surgeon noted aesthetic concerns related to your breast condition and that surgical intervention would be cosmetic in nature. 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 mastectomy for gynecomastia have not been met. Therefore, we decided that the Plan does not have to pre-approve a mastectomy for gynecomastia (19300).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says the clinical information received shows that the enrollee is a long term care resident and does not support the medical necessity of SNF level care.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and had stable vital signs. The enrollee received physical therapy and speech therapy in the SNF. The enrollee was dependent with functional mobility and required varying assist with activities of daily living. The enrollee tolerated a mechanical soft diet and thin liquids. There are no identifiable skilled nursing service needs or skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on January 14, 2020.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that the x-ray was necessary for your oral surgery. 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. The Plan coverage includes a benefit for bitewing x-rays, but not full mouth x-rays. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stereotactic body radiation therapy (SBRT) for the enrollee.
You asked the Plan to pre-approve SBRT. You say that SBRT is medically necessary. The Plan denied your request. The Plan says SBRT is not covered by Medicare for the enrollee's diagnosis.
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 SBRT. Our reviewer says that SBRT has been requested to treat a diagnosis of unresectable extrahepatic biliary cancer. Based on the medical records, the only options discussed in the submitted documentation were standard 6 weeks concurrent chemoradiation and SBRT. The records state the enrollee is too frail for combination therapy and plans sequential addition of chemotherapy after radiation. Based on the treatment planning provided, medical necessity for SBRT has not been established.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to pre-approve Stereotactic body radiation therapy (SBRT) for the enrollee.