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

We decided that the Plan does not have to pre-approve a lightweight manual wheelchair for the enrollee.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not provide any documentation regarding mobility limitations impairing ADLs.
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 wheelchair. Our reviewer says that the requested wheelchair is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the patient's mobility limitation significantly impairs her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. The documentation does not reveal that the enrollee's mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker. The documentation does not reveal that the enrollee's home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided. The documentation does not reveal that the enrollee requires a standard manual wheelchair and therefore the enrollee does not require a lightweight wheelchair. 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a lightweight manual wheelchair for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xarelto 20mg tablets.
You asked the Plan to pre-approve the Xarelto tablets. You say that the enrollee has portal vein thrombosis and this treatment has been effective since April 2019. The Plan denied your request. The Plan says this oral drug is not covered by Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xarelto 20mg tablets.
Benefits for the Xarelto tablets 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on
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 records do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 drug testing services provided to the enrollee on
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvead mission to a skilled nursing facility (SNF).You asked the Plan to pre-approvethe SNF admission. You say that the enrollee needs daily skilled care in the SNF setting.The Plan denied your request. The Plan says the enrollee can be managed with less than daily skilled services.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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a female who was admitted to the hospital with a left humerus fracture. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. Her lungs were clear. Regarding rehabilitation services, the beneficiary received PT and OT in the acute hospital. The beneficiary was at a minimal level with functional mobility including gait to 200 feet hand held assist. The beneficiary required varying assist with ADLs. She was non-weight bearing for her left arm. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; however, these do not require daily skilled therapy services. This beneficiary 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 the SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
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 IRF level care is medically necessary.The Plan denied your request. The Plan says services can be provided at a lower level of care.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 coverage criteria has not been met. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the patient's medical status required the intensity of an IRF stay with close physician or nursing supervision.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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered to enrollee on October 14, 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 procedure code 71045 is not separately payable.The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claim for procedure codes 71045 and 32555. Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 32555. Code 71045 was not billed with an appropriate modifier to allow for separate payment.Therefore,we decided that the Plan does not have to pay forthe chest x-ray rendered to enrollee on October 14, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on September 20, 2019.You asked the Plan to waive the copayment for the colonoscopy. You say that you were charged the outpatient surgery copayment for your colonoscopy due to a polyp being removed.The Plan denied your request. The Plan says the copayment applied correctly.The rules say aplan 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 $400 copayment for, in-network, Medicare-covered outpatient hospital surgery services.You have been asked to pay a $400 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefitcategory. The records show that a polyp was removed, which is considered a surgical procedure. 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 colonoscopy provided on September 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9502) provided on November 30, 2019 through December 9, 2019.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code S9502 has a status code of I which is not valid for Medicare purposes.
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 S9502 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9502 has a status code of I. This means the CPT code S9502 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9502) provided on November 30, 2019 through December 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Tacrolimus for enrollee.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 drug is not eligible for a tier exception.The Plan must follow Medicare rules. The rules say that if payment for a drug could be available under Part A or Part B to the individual for such drug, then it will not be covered under Part D. We looked at the file and Medicare rules. The requested drug is covered by Part B and is not eligible for a Part D tier exception.Therefore, we decided that the Plan does not have to pre-approve a tier exception for Tacrolimus for enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of a Superion interspinous spacer.You asked the Plan to pre-approve the Superion spacer. You say that this is the best option for the patient's condition.The Plandenied your request. The Plansaysthis cannot be covered in a patient with severe stenosis and levoscoliosis.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 Superion spacer. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed.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 Superion spacer have not been met.Therefore, we decided that the Plandoes not haveto pre-approveplacement of a Superion interspinous spacer.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea tier exception for PERFOROMIST for the enrollee.You asked the Plan to pre-approvea tier exception. The Plan denied your request. The Plan says that tier exceptions only apply to Part D drugs.The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D drugs. The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for coverage of a tier exception have not been met.Therefore, we decided that the Plan does not have to pre-approvea tier exception for PERFOROMIST for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, such as a skilled nursing facility, home with home health and home physical therapy, or home with outpatient therapy.
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 your medical conditions appear stable. There are no wound care needs. There are no identified unaddressed medical issues. You are currently in an outpatient setting and do not require an acute hospital level of care. You are limited by debility and the severity of your comorbid medical conditions. You would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact your condition differently compared with therapy provided at a less intense level. Your care can be appropriately provided at a SNF level. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a pontic - porcelain fused to high noble metal (D6240), a custom fabricated abutment for tooth #4 (D6057), and an abutment supported porcelain fused to metal crown x2 for tooth #4 (D6059).
You asked the Plan to pay for the pontic - porcelain fused to high noble metal (D6240), the custom fabricated abutment for tooth #4 (D6057), and the abutment supported porcelain fused to metal crown x2 for tooth #4 (D6059). You say that the services are medically necessary. The Plan denied your request. The Plan says significant medical records were not provided to show medical necessity for the pontic - porcelain fused to high noble metal (D6240). The custom fabricated abutment for tooth #4 (D6057) and the abutment supported porcelain fused to metal crown x2 for tooth #4 (D6059) are not covered benefits.
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 the pontic - porcelain fused to high noble metal (D6240) when the service is medically necessary and reasonable. 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 pontic - porcelain fused to high noble metal (D6240). Our reviewer says that the pontic - porcelain fused to high noble metal (D6240) is not medically necessary. Our physician reviewer found that the documentation was incomplete since radiographs were not included in the case. Therefore, a determination of medical necessity was not possible.
Though the Plan offers a dental benefit in excess of Medicare coverage, the custom fabricated abutment for tooth #4 (D6057) and the abutment supported porcelain fused to metal crown x2 for tooth #4 (D6059) are not among those covered under this benefit.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the pontic - porcelain fused to high noble metal (D6240), the custom fabricated abutment for tooth #4 (D6057), and the abutment supported porcelain fused to metal crown x2 for tooth #4 (D6059) have not been met. Therefore, we decided that the Plan does not have to pay for the pontic - porcelain fused to high noble metal (D6240), the custom fabricated abutment for tooth #4 (D6057), and the abutment supported porcelain fused to metal crown x2 for tooth #4 (D6059).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).You asked the Planto pre-approvethe SNF admission. You say that the enrollee has had surgery and needs to get continued care in the SNF setting.The Plandenied your request. The Plansaysthe enrollee has not started a new benefit period and has used the maximum 100 day SNF benefit.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from June 19, 2019 to March 13, 2020. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intense pulsed light (IPL) therapy.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 considered experimental/investigational and 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 records show that you are diagnosed with meibomian gland dysfunction in both eyes. There is some evidence that IPL is effective for this condition; however, the studies to date are limited by design and size. The majority of evidence is from trials that do not compare IPL to standard treatment; therefore, the services are not considered medically necessary or more helpful than other standard treatments.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 intense pulsed light (IPL) therapy.
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 these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
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 these services 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 pre-approve injections of Orthovisc.You asked the Plan to pre-approve Orthovisc. You say that the enrollee is not interested in any type of surgical intervention at this time, and viscosupplementation would allow the enrollee to remain as active as possible.The Plan denied your request. The Plan says the denial of authorization for Orthovisc is correct, because Orthovisc is not recommended for use in enrollees with symptomatic osteoarthritis of the knee and no documentation was submitted regarding the enrollee's response to conservative treatment.The Plan must follow Medicare rules. The rulessay 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 wascorrect in denying the request to pre-approve Orthovisc. Our reviewer says that the enrollee does not meet the Medicare criteria for use of Orthovisc. Our physician reviewer found evidence-based medical peer-reviewed literature supports the use of viscosupplementation injections as an option for the treatment of pain in patients with osteoarthritis of the knee. Current evidence-based medical guidelines state that medical evidence suggests intra-articular hyaluronic acid injections may relieve osteoarthritic knee pain in some patients. In this case, there is no evidence that the corticosteroid injections and/or knee braces given to the enrollee failed to provide adequate relief. Additionally, there is no evidence of failure of other first line conservative treatment including activity modification, nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, and exercise to support proceeding with viscosupplementation at this time. Therefore, the documentation does not support that the Orthovisc injections requested are medically reasonable and necessary or safe and effective for the enrollee at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovischave not been met.Therefore, we decided that the Plan does not have to pre-approveinjections of Orthovisc.