Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Heavy-Duty Universal Scooter Lift.You asked the Plan to pre-approvea vehicle wheelchair lift. You say that the enrollee is unable to self-roll the wheelchair into the vehicle. The Plandenied your request. The Plan says changes or improvements to real property such as a vehicle lift 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 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.Also,the item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approvea Heavy-Duty Universal Scooter Lift.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve full length bed rails (E0310).You asked the Plan to pre-approve the bed rails. You say that you were using half rails on the bed but the enrollee is still able to get out of the bed and you are concerned that she will fall out of bed and seriously injury herself like she has done before.The Plan denied your request. The Plan says this item is not a covered benefit. Side rails used as a restraint to prevent falls or wandering are not considered medically necessary.The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve full length bed rails (E0310).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested IRF care is not considered medically
reasonable and necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee presented to the hospital on June 15, 2020 with acute onset of back pain.
The enrollee was found to have a new compression fracture of the T12 vertebrae which was treated with
kyphoplasty on June 22, 2020. Neutral spine precautions are in place. Now, the enrollee is able to make needs
known. Pain is appropriately managed with medications. A thoracic lumbar sacral orthosis (TLSO) is in use.
Ambulation is performed, as are transfers, with minimal assistance. There is no hemodynamic instability or
signs of toxicity.
Records do not indicate that there are significant, or complex medical/nursing issues that could not be
addressed at a lower level of care. Ongoing pain medication and other medication management, wound care,
and daily therapy can be provided at a lesser level of care. In this case, the member is mostly minimal assist
for functional transfers and activities of daily living and a less intensive, longer duration of therapy will allow
for measurable gains to be attained within a predicted period.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on November 15, 2019. 
 
You asked the Plan to pay for the knee orthosis (L1833) and suspension sleeve (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says rules for telehealth services were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on November 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zafirlukast Tab.
You asked the Plan to pre-approve Zafirlukast Tab. You say that you want the enrollee treated with this drug.
The Plan denied your request. The Plan says this medication does not fall under the enrollee's Medicare Part B
benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Zafirlukast Tab.
Benefits for Zafirlukast Tab 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: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99204) provided on December 12, 2019 by a Medicare opted-out provider. You asked the Plan to pay for the office visit provided by a Medicare opted-out provider. You say that you were not aware the provider was opted-out of Medicare and that the services would not be reimbursed. The Plan denied your request. The Plan says services provided by a Medicare opted-out provider are not covered. The plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given by a physician or other practitioner who has opted out of Medicare. We looked at case file and the Medicare rules. We confirmed that the provider has opted out of Medicare. Based on this information, we decided that Medicare rules for coverage of the office visit provided by a Medicare opted-out provider have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99204) provided on December 12, 2019 by a Medicare opted-out provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (G0249) provided on December 30, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the frequency limit has
been exceeded.
The Plan must follow Medicare rules. Medicare rules say that that code G0249 is payable once every 25.
We looked at the file and Medicare rules. The records show that code G0249 was paid on for date of service
December 16, 2019. The requested services were provided within 25 days of the paid claim, which means that
the benefit limit has been exceeded. 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
(G0249) provided on December 30, 2019.
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 a CGM. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says you do not meet Medicare criteria. The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. Medicare guidelines say that in order for a CGM to be covered, all of the above criteria must be met. The enrollee must have been using a BGM and performing frequent (four or more times a day) testing. Medicare also says therapeutic CGMs are covered when the enrollee is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. In this case, the file shows that you do not perform four or more blood glucose testing per day and that you are not insulin treated with multiple (three or more) daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met.Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for blepharoplasty (15823) and related procedures (67999 and L8610) provided on August 1, 2019. You asked the Plan to pay for blepharoplasty and related procedures. You say that this was medically necessary. The Plan denied your request. The Plan says that the documentation does not include a visual field exam to support medical necessity. The Plan follows Medicare rules. Medicare rules say blepharoplasty may be considered reconstructive when performed for the repair of anatomical or pathological defects, including those caused by disease (including thyroid dysfunction and cranial nerve palsies), trauma, or tumor-ablative surgery. 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 blepharoplasty and related procedures. Our reviewer says that the procedures at issue were medically necessary. Our physician reviewer found the criteria states that a patient can undergo repair of an anatomical defect, including those caused by a disease such as cranial nerve palsy. Surgery should be performed to reconstruct the normal structure of the eyelid, using local or distant tissue. The member has a post-traumatic defect of the eyelid. She has facial paralysis resulting in an abnormal eyelid on the side of the palsy. Therefore, surgery to fix the defect is not considered cosmetic. If a patient cannot close and open her eye properly, the patient can develop vision loss and functional loss of the eye. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of blepharoplasty and related procedures have been met. Therefore, we decided that the Plan has to pay for blepharoplasty (15823) and related procedures (67999 and L8610) provided on August 1, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for Emergency Room services (99284) provided October 11,
2019.
You asked the Plan to pay for the Emergency Room Services. You say that the services were medically
necessary. The Plan denied your request. The Plan says another claim was submitted by the same physician's
group for the same service date.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 99284 is not supported in the medical record. Specifically, the record shows that a
claim for this service was already submitted by another physician from the same group and has already been
processed. Based on this information, we decided that Medicare rules for coverage of the Emergency Room
Services have not been met. Therefore, we decided that the Plan does not have to pay for Emergency Room
services (99284) provided October 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller, expandable controller harness, electronic connection and power seat elevation feature. You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan denied your request. The Plan says that there is not a medical need to control these power options through the joystick. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature. 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 items. Our reviewer says that the expandable controller, expandable controller harness and electronic connection are not considered medically reasonable and necessary in this case. There is no information in the record justifying the need for control of the power options through the joystick. There is no documentation stating that you do not have the physical function and strength to control separate switches for the power functions and that there is a medical need for these options. Our physician reviewer found that your condition does not meet Medicare criteria for the expandable controller, expandable controller harness and electronic connection. 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 items have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller, expandable controller harness, electronic connection and power seat elevation feature.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda. You asked the Plan to pre-approve Keytruda. You say that the requested Keytruda is medically necessary. The Plan denied your request. The Plan says the requested Keytruda is not medically necessary. The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Keytruda. Our reviewer says that the requested Keytruda is not medically necessary. Our physician reviewer found the enrollee is with metastatic small bowel cancer that is MSI intact, MMR-proficient with PDL-1 CPS 20. Keytruda is not FDA approved for this indication. Keytruda is not supported in any of the CMS approved compendia. This reviewer did not find any supporting citations in a PubMed search. The NCCN Guidelines Version 2.2020 Small Bowel Adenocarcinoma page SBA-D 1 of 7 does not include Keytruda for use in patients with pMMR/MSS. And on page SBA-D 5v of 7 the drug is listed as only for tumors with dMMR/MSI-H. The use is not listed as not indicated, not supported, or not recommended in any of the compendia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF care. You say that an inpatient skilled nursing facility admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an inpatient skilled nursing facility admission.
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 an inpatient skilled nursing facility admission is not medically necessary. Our physician reviewer found that you do not require skilled nursing or skilled therapy services on a daily basis. Additionally, you do 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the office services provided on February 18, 2020 by an outof-network provider. 
 
You asked the Plan to pay for the office services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the provider has never been a contracted provider with 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 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 office services provided on February 18, 2020 by an out-of-network provider.
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 SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you do not require complex daily nursing care that must be provided in a skilled nursing facility. 
 
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 that your condition does not meet Medicare criteria for SNF 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 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan
denied your request. The Plan says the service is a covered benefit, but the enrollee has exceeded the benefit
limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 36 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear purchased on November 29, 2019. You asked the Plan to pay for the eyewear. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says you exhausted your maximum benefit allowance. 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. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. You exhausted your maximum benefit allowance, because the plan paid $150 for your eyewear. Your EOC states, the plan provides a $150 allowance once every twenty-four (24) months for you to use toward the purchase price of eyewear from a plan optical facility when a physician or optometrist prescribes an eyeglass or contact lens for vision correction. If the eyewear you purchase costs more than $150, you pay the difference. Therefore, we decided that the Plan does not have to pay for the eyewear purchased on November 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wig and wig maintenance provided January 15, 2019 to June 15, 2019.
You asked the Plan to pay for the wig. You say that you have alopecia The Plan denied your request. The Plan says this service is not covered under the plan benefits.
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan contract on page 10 specifically says that the Plan only covers wigs for hair loss due to chemotherapy. Therefore, we decided that the Plan does not have to pay for the wig and wig maintenance provided January 15, 2019 to June 15, 2019.