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

We decided that the Plan does not have to pre-approve seat lift mechanism, electric, any type (CPT Code E0627).
You asked the Plan to pre-approve the DME. You say that you cannot stand up on your own because of the weakness and tingling in your arms and legs. You state you have wounds to both legs and have had surgeries on both legs over the past three (3) years. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. You are able to stand from a seated position from a regular armchair. Therefore, we decided that the Plan does not have to pre-approve seat lift mechanism, electric, any type (CPT Code E0627).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided to the
enrollee on June 26, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you should not be
responsible for payment because services were not necessary. The Plan denied your request. The Plan says that
you are responsible for the cost share.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200
copayment for Ambulance services.
You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls
within the Ambulance services benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for
the ambulance transport provided to the enrollee on June 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for power seat lift chair.
You asked the Plan to pay for the power seat lift chair. You say that the durable medical equipment is
medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the power seat lift chair have not been met. You are independent
with transfers. You do not need help to sit and stand. A power seat lift chair can only be approved for members
who need hands on help from others to sit and stand from standard height surfaces. It may also be approved if
the member needs other seating options due to a medical condition. You do not have the condition that is
needed to be approved for a power seat lift chair. Therefore, we decided that the Plan does not have to pay for
power seat lift chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an outpatient hospital visit on September 4, 2019.You asked the Plan to waive the coinsurance foran outpatient hospital visit. You say that you have never been charged in the past and disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for each outpatient hospital visit.You had an outpatient hospital visit on September 4, 2019. The allowed amount is $148.40 and 20% of that is $29.68.  You have been asked to pay the total coinsurance amount of $29.68 for an outpatient hospital visit. An outpatient hospital visit falls within the outpatient hospital services 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 whenyou enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance foran outpatient hospital visit on September 4, 2019.
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 member is motivated to participate in 3 hours of therapy a day and does not believe they will make the necessary gains in lower level of care. The Plan denied your request. The Plan says IRF admission is not medically 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 complexity of the member'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 member required the intensity of an IRF stay with close physician or nursing supervision. The member does not require Physical or OccupationalTherapy or appear to be able to tolerate this therapy on an intensive rehabilitation facility therapy program level in an IRF.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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient behavioral health care from January 11, 2020, forward.You asked the Plan to pre-approve continued inpatient behavioral health care. The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient behavioral health care. Our reviewer says that the requested inpatient behavioral health care is not medically reasonable and necessary. Our physician reviewer found that the enrollee was compliant with treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or others but was compliant with her treatment.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 inpatient behavioral health care have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued inpatient behavioral health care from January 11, 2020, forward
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the dimethyl sulfoxide injections provided
on August 5, 2019 and August 12, 2019.
You asked the Plan to waive the coinsurance for the injections. You say that you never had to pay previously.
The Plan denied your request. The Plan says that cost share is a contractual obligation under the plan and
cannot be waived.
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 20%
coinsurance for Medicare Part B Prescription Drugs.
You have been asked to pay a 20% coinsurance for the injections. The injections fall within the Medicare Part
B Prescription Drugs 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 coinsurance for the
dimethyl sulfoxide injections provided on August 5, 2019 and August 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe glucose monitor, test strips, lancet, control solution, and lancet device provided from August 9, 2019 to October 28, 2019.You asked the Plan to pay forthe glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not includethe carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancet, control solution, and lancetdevice provided from August 9, 2019 to October 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee orthosis (ko), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf (CPT Code L1852), for the enrollee.You asked the Plan to pre-approvethe knee orthosis. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee orthosis have not been met. The medical records we received from your healthcare provider did not show instability in your right knee when your provider examined your knee.Therefore, we decided that the Plan does not have to pre-approveknee orthosis (ko), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf (CPT Code L1852), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the humidifier (CPT Code E0560). You asked the Plan to pre-approvethe DME. You say that you are requesting review of denial of the air purifier.The Plan denied your request. The Plan says the Medicare rules have not been met.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. The air purifier is not covered because it is a convenience item.Therefore, we decided that the Plan does not have to pre-approvethe humidifier (CPT Code E0560).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carisoprodol 350 MG tablets.
You asked the Plan to pre-approve Carisoprodol tablets. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says Carisoprodol tablets are not covered 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 Carisoprodol 350 MG
tablets.
Benefits for Carisoprodol 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a CT Scan of the abdomen (74175) and CT Scan of the pelvis (72191).You asked the Plan to pre-approve the CT Scans. You say that the CT Scans are medically necessary. The Plan denied your request. The Plan says that the records do not showthat the timeframe guidelines have been followed.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 the CT Scans. Our reviewer says that the CT Scans are medically reasonable and necessary. Our physician reviewer found CT monitoring is warranted every 6 months for the first 2 years following repair and annually after that if stable. However, as there is sufficient evidence of their condition not being stable with widening in a setting of a possible endoleak which warrants a return to a 6-month monitoring plan to see if widening is worsening.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 CT Scans have been met. Therefore, we decided that the Plan has to pre-approve a CT Scan of the abdomen (74175) and CT Scan of the pelvis (72191).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the negative pressure wound therapy electrical pump provided on August 12, 2019 by out of network provider.You asked the Plan to pay fornegative pressure wound therapy electrical pump (E2402). You say that thenegative pressure wound therapy electrical pump was medically necessary.The Plan denied your request. The Plan says you did not have 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 forthe negative pressure wound therapy electrical pump provided on August 12, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee scooter.
You asked the Plan to pre-approve a knee scooter (E0118). You say that you won't be able to go out beyond your own residence and take care of your errands. The Plan denied your request. The Plan says there is insufficient clinical literature demonstrating safety and effectiveness of a knee scooter.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. 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. Knee scooters are not covered by Medicare or the Plan. Based on this information, we decided that Medicare rules for coverage of a knee scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee scooter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided on August 4, 2019.You asked the Plan to waive the copayment foran ambulance trip. You say that you were told by the provider that you would not owe a copayment.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for ambulance services. You have been asked to pay a $200 copayment for an ambulance trip. An ambulance trip falls within the ambulance services 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 foran ambulance trip provided on August 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from August 15, 2019 through August 18, 2019.You asked the Plan to waive the copayment forinpatient hospital care. You say that you were never taken to the intensive care unit (ICU).The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received inpatient hospital care from August 15, 2019 through August 18, 2019. You are asked to pay a $355 copayment per day from August 15, 2019 through August 17, 2019, days 1-3 of your inpatient hospital care. You were discharged on August 18, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $355 copayment per day required for days 1-5. An inpatient acute admission has the same copay whether you are in a general room or the ICU. 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 forinpatient hospital care from August 15, 2019 through August 18, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medication Procrit (J0885).
You asked the Plan to pre-approve this medication. You say that Procrit is medically necessary based on the
member's medical history of chronic kidney disease, stage 3, with chronic anemia. The Plan denied your
request. The Plan says the requested drug is subject to step therapy. This requirement encourages you to try our
preferred drug Retacrit, which is just as effective. Documentation or medical records supporting the medical
necessity for a step therapy exception were not provided.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 this medication. Our reviewer says that
the enrollee does not meet criteria for coverage of the medication Procrit. Our physician reviewer found the
patient has not tried and failed the required drug Retacrit. Based on the patient's medical history, the Plan's
preferred drug Retacrit is medically appropriate and would not be less effective than the requested drug or have
adverse effects for the 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 this medication have not been met. Therefore, we decided that the Plan does not
have to pre-approve the medication Procrit (J0885).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the robotic surgical system services rendered on September 16, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code S2900 is not covered.The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes.The provider submitted a claim for procedure code S2900 (Surgical techniquesrequiring use of robotic surgical system). This code has a status indicator of I and is not valid for Medicare purposes.Therefore, we decided that the Plan does not have to pay forthe robotic surgical system services rendered on September 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forCPT code 81479 (BRCA Analysis) provided on September 5, 2019.You asked the Plan to pay forCPT code 81479. You say that the BRCA Analysis provided was medically necessary.The Plan denied your request. The Plan says the BRCA Analysis provided did not meet criteria.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 CPT code 81479. Our reviewer says that the BRCA Analysis provided did not meet criteria. Our physician reviewer found the enrollee is with history of ER+ breast cancer, diagnosed after the age of 65. The enrollee has no relatives with cancer. Based on the documentation provided for review, the enrollee does not meet Medicare criteria for the BRCA Analysis provided. The documentation shows that the enrollee's family did not have any known deleterious BRCA1 or BRCA2 gene mutation, the enrollee does not have a personal history of ovarian cancer, the enrollee was diagnosed with breast cancer after 45 years of age, the enrollee was not diagnosed with triple negative breast cancer at less than or equal to 60 years of age, does not have family with any type of cancer, does not have a personal history of prostate cancer or pancreatic cancer, and is not of Ashkenazi Jewish ancestry.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 81479 have not been met.Therefore, we decided that the Plan does not have to pay forCPT code 81479 (BRCA Analysis) provided on September 5, 2019.