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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, the enrollee does not require skilled nursing or skilled therapy services on a daily basis. The Medical records do not show the enrollee meets a severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve the office visit and injection. You say that you would like reconsideration
because you would like to continue seeing this provider. The Plan denied your request. The Plan says you do
not have out-of-network benefits and the requested services can be provided by a participating provider.
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
the medical services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gemfibrozil. 
 
You asked the Plan to pre-approve Gemfibrozil. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Part B plan. 
 
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 Gemfibrozil.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6536 that were issued on February 26, 2020. 
 
You asked the Plan to pay for the compression stockings. You say that you verified with insurance that this was a covered item. The Plan denied your request. The Plan says gradient compression stockings are noncovered because they do not meet the statutory definition of a dressing. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6536 are noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6536 that were issued on February 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of ferric carboxymaltose (injectafer).
You asked the Plan to pre-approve injectafer. You say that the enrollee needs this because he has trouble
swallowing iron supplementation in pill form. The Plan denied your request. The Plan says the denial of
authorization for this drug is correct, because the record does not address whether the enrollee can use liquid
iron for his iron deficiency anemia.
The Plan must follow Medicare rules. The rules say 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 was correct in denying the request to pre-approve injectafer. Our reviewer says that the
enrollee does not meet the Medicare criteria for use of injectafer. Our physician reviewer found the
documentation submitted does not indicate that the enrollee has tried and failed oral liquid iron. The Food &
Drug Administration (FDA) indication and drug compendia supported uses of injectafer are for patients who
have intolerance to oral iron, have had unsatisfactory response to oral iron, or who have non-dialysis dependent
chronic kidney disease. Therefore, the documentation does not support that the requested injectafer is
medically reasonable and necessary 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 injectafer have not been met. Therefore, we decided that the Plan does not have
to pre-approve use of ferric carboxymaltose (injectafer).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from February 12, 2020 to March 9, 2020. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claims were not billed correctly. The Plan must follow Medicare rules. The rules say that home health claims must be billed with the proper HIPPS code. We looked at the file and Medicare rules. The file shows that the claims were not billed with the required HIPPS code. 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 pay for the home health services rendered from February 12, 2020 to March 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on March 10, 2020 by a non-
Medicare provider.
You asked the Plan to pay for the dental services. You say that when you signed up with the Plan you were
never told that you could not use providers who have opted out of Medicare. The Plan denied your request. The
Plan says the provider opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for
the dental services provided on March 10, 2020 by a non-Medicare provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cold pack with pump.
You asked the Plan to pre-approve the requested items. You say that without the cold therapy unit, the surgery is at risk of not being done. The Plan denied your request. The Plan says the pump is excluded from your benefit.
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 requested device is not covered by Medicare or your plan. Therefore, we decided that the Plan does not have to pre-approve a cold pack with pump.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Leucovorin Calcium. 
 
You asked the Plan to pre-approve the requested drug. The Plan denied your request. The Plan says the drug is not supported 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 the requested drug. Our physician reviewer found that the enrollee has stage II colon cancer. The notes state the enrollee has an elevated CEA, but there is no documentation of the result. The requested use of Leucovorin Calcium is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The requested use is listed as not indicated, not supported or not recommended. 
 
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 requested drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Leucovorin Calcium.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low-dose computed tomography (LDCT) lung cancer screening.
You asked the Plan to pre-approve LDCT lung cancer screening. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee is not between 55 to 77 years of age and does not have a tobacco smoking history of at least 30 pack-years.
The Plan must follow Medicare rules. Medicare rules say that LDCT lung cancer screenings are only covered for enrollees between the ages of 55 to 77 who meet all of the specific criteria listed above. We looked at the file and Medicare rules. The enrollee is not between the ages of 55 to 77. Furthermore, the enrollee does not have a documented tobacco smoking history of at least 30 pack-years. Based on this information, we decided that Medicare rules for coverage of LDCT lung cancer screening have not been met. Therefore, we decided that the Plan does not have to pre-approve a low-dose computed tomography (LDCT) lung cancer screening.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient surgery (57410, 58571, 38500) services to be provided by an out of network (OON) provider. You asked the Plan to pre-approve OON outpatient surgery. You say that this will be performed at an in-network facility. The Plan denied your request. The Plan says these services are available from in-network providers. 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 the outpatient surgery (57410, 58571, 38500) services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a footplate width extension, specialty controller, egg switches and mount, extension cables, Bluetooth interface, square tubing, and knee positioner all identified with code K0108. You asked the Plan to pre-approve these wheelchair accessories. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not covered. The Plan must follow Medicare rules. Medicare rules say that K0108 can only be used for items without a proper HCPCS code. Review of the file shows that an expandable harness has already been approved. The requested items already have the switches, wires, circuits, and mounting hardware needed for them to function. Code K0108 is not to be used for any part of the expandable controller. The request for the I-drive Bluetooth control interface and the extension cable is unbundled from the previously approved expandable controller.  The reimbursement for any type of complete expandable controller is included in the allowance for codes E2377/E2376 plus E2313. Code K0108 cannot be used for any component of the harness. This request is unbundled from previously approved E2313 expandable harness. Review of the file also shows that code E1012 power elevating leg rests have already been approved. This includes foot plates and foot platforms. Therefore, the request for the bracket footplate width extension with mounting hardware is non-covered as code E1012 includes all components of the leg rest, including fixed angle footplates and foot platforms. The code used for footplates does not match the items requested. E1012 power elevating leg rests have been approved. The requested footplates are unbundled and miscoded. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these wheelchair accessories have not been met. The requested items should not be requested with codes K0108 unless there is not another proper HCPCS code. Therefore, we decided that the Plan does not have to pre-approve a footplate width extension, specialty controller, egg switches and mount, extension cables, Bluetooth interface, square tubing, and knee positioner all identified with code K0108.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (CPT Code 99231) on January 13, 2020.
You asked the Plan to pay for the services. You say that the claim should be paid. 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 services have not been met. The CPT code 99231 denied because it was reported for a participant in a clinical research program and was reported without a required modifier within the previous or subsequent 30 days. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (CPT Code 99231) on January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider. You asked the Plan to pre-approve office visit. You say that there are no in-network maxillofacial specialists who are taking new patients at this time. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network oral and maxillofacial specialist. 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 the medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the Plan does not authorize care that cannot be provided within the network.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a duplex scan to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve a duplex scan. You say that the enrollee can not ambulate. The Plan denied
your request. The Plan says there are in-network providers available for these services.
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. It is the responsibility 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 duplex scan 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 96 additional routine transports.
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 enrollee has exhausted 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 48 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 96 additional routine transports.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that you require the stockings because
you are diabetic and you have peripheral neuropathy which causes pain and swelling. The Plan denied your
request. The Plan says the stockings are not covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6549.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing for facioscapulohumeral muscular dystrophy 1A (FSHMD1A).
You asked the Plan to pre-approve the FSHMD1A genetic testing. You say that this testing is medically necessary and should be covered. The Plan denied your request. The Plan says this testing is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that certain genetic testing is not covered because it is unlikely to impact therapeutic decision-making, directly impact treatment, outcome and/or clinical management in the care of the beneficiary. Testing for FSHMD1A is one of the tests that Medicare does not consider reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve genetic testing for facioscapulohumeral muscular dystrophy 1A (FSHMD1A).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the
case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to
pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician
reviewer found based on the medical records provided, the documentation does not show the enrollee requires
daily skilled nursing and/or daily skilled nursing services at a SNF level of care. We looked at this physician's
review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of
SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled
nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health treatment. You asked the Plan to pre-approve inpatient mental health treatment. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met. 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 inpatient mental health treatment. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based upon review of the records provided, you do not meet the criteria for continued acute inpatient mental health treatment for the dates in question of July 23, 2020 forward as you were not shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations and were not showing any threats to the safety of yourself or others. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health treatment.