Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental consultation to be provided by an out of network dentist.
You asked the Plan to pre-approve the dental service. You say that you need tooth # 14 to be restored. You say that this is a result of previous medical dental malpractice by a different vendor. The Plan denied your request. The Plan says dental service performed out of network are not covered.
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, dental services to be performed out of network are not among those covered under this benefit. Additionally, the record shows that the Plan has approved an oral evaluation with an in network provider. Therefore, we decided that the Plan does not have to pre-approve a dental consultation to be provided by an out of network dentist.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 5, 2021, to March 9, 2021.
You asked the Plan to pay for the acute inpatient hospital care. You say that the enrollee met inpatient criteria with multiple factors. The Plan denied your request. The Plan says a medical need for an inpatient hospital stay has not been shown because there was no evidence of fever, immunocompromise, worsening cognition, or
significant pain. The Plan also says that this request does not show why the enrollee could not have been treated at an observation level of care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was near baseline but clearly required fluids and antibiotics for her urinary tract infection, which appeared to be uncomplicated and had not failed outpatient treatment. The enrollee was hemodynamically stable, and the emergency department course was not complicated. Our reviewer also found that it was not expected that the enrollee would require hospital services that would likely cross 2 midnights. 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 5, 2021, to March 9, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device.
You asked the Plan to pre-approve a pneumatic compression device. You say that the enrollee needs this device. The Plan denied your request. The Plan says the requirements for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device (PCD) is covered for the treatment of chronic venous insufficiency of the lower extremities only if the patient has one or more venous stasis ulcers that have failed to heal after a six-month trial of conservative therapy directed by the treating practitioner. We looked at the file and Medicare rules. The submitted medical records do not show that the enrollee has venous stasis ulcers that have failed to heal after a six-month trial of conservative therapy Based on this information, we decided that Medicare rules for coverage of a pneumatic compression device have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve rimabotulinumtoxin (Myobloc).

You asked the Plan to pre-approve Myobloc. You say that the type B toxin is much more preferable. The Plan denied your request. The Plan says the enrollee has not tried and failed Xeomin.

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 Myobloc. Our physician reviewer found that the enrollee has Parkinson's disease with excessive drooling. The Plan requires a trial of Xeomin before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug. There is no documentation provided indicating that the Plan's required drug would likely be less effective or likely 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 Myobloc have not been met. Therefore, we decided that the Plan does not have to pre-approve rimabotulinumtoxin (Myobloc).
Appeal type: Drugs
Decision: Unfavorable


We decided that the Plan does not have to pre-approve Cabometyx and Atezolizumab. 
 
You asked the Plan to pre-approve Cabometyx and Atezolizumab. You say that this drug combination is 
medically necessary for the enrollee's medical condition. The Plan denied your request. The Plan says this drug 
combination is experimental for the enrollee's condition. 
 
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 Cabometyx and Atezolizumab. Our 
reviewer says that the requested drug combination is not medically necessary and reasonable. Our physician 
reviewer found the enrollee has been diagnosed with metastatic castration-resistant prostate cancer diagnosed 
in 2016. In this case, the requested drug combination is not considered standard treatment for the enrollee's 
condition. Of note, the trial mentioned was for non-small cell lung cancer. In addition, the use of these drugs is 
not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved 
medical journal for the enrollee's medical condition.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cabometyx and Atezolizumab have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Cabometyx and Atezolizumab.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and accessories to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that these items are medically 
necessary. The Plan denied your request. The Plan says in-network providers are available to provide this 
equipment. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.  
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a power wheelchair and accessories to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two pontics (D6241 x2) and four retainer crowns (D6751 x4).

You asked the Plan to pre-approve the pontics and retainer crowns. You say that you are trying to prevent severe pain and would like your teeth to be fixed. The Plan denied your request. The Plan says these services are not covered under your plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two pontics (D6241 x2) and four retainer crowns (D6751 x4).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional Logisticare mileage.
You asked the Plan to pre-approve the additional Logisticare mileage. You say that most of your doctors are
located at the same facility, 124 miles away from your residence. You say that you were hospitalized as a result
of your medical condition. You also say that you need these rides because you cannot afford to go to these
doctors otherwise. The Plan denied your request. The Plan says each one-way trip is covered up to a 50-mile
driving distance. The Plan also says that the request for additional miles exceeded the benefit.
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 routine transportation when each one-way trip must not exceed 50 miles of driving
distance. A trip is one-way transportation; a round trip is 2 trips. You are responsible for any costs over the trip
limit. We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan's rules for coverage of routine transportation have not been met. Specifically, trips more than a 50-mile driving distance exceed the benefit. Therefore, we decided that the Plan does not have to pre-approve
additional Logisticare mileage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns, porcelain fused to high noble metal, (D2750) for teeth # 22 and 28.
You asked the Plan to pre-approve the dental services. You say that you are getting a root canal. You also say that you need a crown after. The Plan denied your request. The Plan says porcelain fused to high noble metal crowns are 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 porcelain fused to high noble metal crowns are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve crowns, porcelain fused to high noble metal, (D2750) for teeth # 22 and 28.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
You asked the Plan to provide a therapeutic continuous glucose monitor. You say that the enrollee meets criteria for a CGM. The Plan denied your request. The Plan says the enrollee is not adjusting insulin doses or testing four or more times a day.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day nor requires frequent self-adjustment of insulin dosage based on the blood glucose testing results. The enrollee pharmacy history shows test strips refills are filled for twice a day testing. There is no record of frequent self-adjustment of insulin dosage. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitor
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a backup manual wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that the enrollee is unable to walk from the car to a public rest room if she is out in the car. The Plan denied your request. The Plan says payment is only made for one wheelchair at a time.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 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-approve a backup manual wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says they will continue to cover medically necessary acute and critical care at the current facility until the enrollee's condition is stable enough for transfer to an alternate level of care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted with hypoxic respiratory failure due to COVID-19 pneumonia. The enrollee is clinically improving. The enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met because the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that the enrollee is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 in the Medicare rules section. 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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was
admitted for Coronavirus pneumonia Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy (45378) provided on January 21, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $325 copayment for a surgical service provided at an outpatient hospital facility.
If you receive a colonoscopy without previous symptoms, this is considered preventive and there will be no copay or coinsurance. If your doctor is performing the colonoscopy because you have shown symptoms of a medical condition, this is considered outpatient surgery. You have been asked to pay a $325 copayment for the outpatient surgery provided. 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 diagnostic colonoscopy (45378) provided on January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the procedure code billed as 99285.
You asked the Plan to pay for the procedure code billed as 99285. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the medical rec
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 99285 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high
severity and pose an immediate significant threat to life or physiologic function. We asked our coder 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 procedure code billed as 99285. Our reviewer says that the documentation does not support the requested code as billed. Our reviewer found the patient is a 79-year-old female following a mechanical fall from her foot slipping. She hit her head on the left side but did not lose consciousness. She complained of head and neck pain, moderate in severity. She was diagnosed and treated for a 2 cm laceration and imaging was negative (CT head/neck). 99285 was coded for the emergency department care received. Based on the lower severity presentation and treatment received in the ED, 99284 would be a more appropriate code. Therefore, the documentation does not support the code, 99285. 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 procedure code billed as 99285 have not been met. Therefore, we decided that the Plan does not have to pay for the procedure code billed as 99285.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on April 13, 2021.
You asked the Plan to pay for a comprehensive oral evaluation. You say that you had to change providers and this service was done as a new patient. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 3 Plan years
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on June 4, 2020. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on April 13, 2021.