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

We decided that the Plan has to pre-approve a Purewick female external catheter.

You asked the Plan to pre-approve a Purewick female external catheter. You say that the requested Purewick female external catheter is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for a Purewick female external catheter.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 a Purewick female external catheter. Our reviewer says that the enrollee meets criteria for a Purewick female external catheter. Our physician reviewer found in this case, the enrollee has had a stroke and has hemiplegia. Additional records were requested and received. The enrollee has urinary incontinence documented back to November 2020. The enrollee has tried and failed Myrbetriq and oxybutynin. The permanence test is satisfied. The elements of the coverage criteria are satisfied. The requested service is 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 a Purewick female external catheter have been met. Therefore, we decided that the Plan has to pre-approve a Purewick female external catheter.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approve 2 levels of RFA. We decided that the Plan does not have to preapprove
1 level of RFA.

You asked the Plan to pre-approve radiofrequency ablation. You say that the enrollee is in pain. The Plan says
that the procedure to be performed on 3 levels is not medically necessary.

We decided that the Plan has to pre-approve 2 levels of RFA.

The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is only covered under certain
medical indications.

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 services. Our physician
reviewer found that the enrollee has chronic axial low back pain, which has not been improved with
conservative therapy. The enrollee had greater than 80% pain relief from 2 sets of diagnostic MBBs. 3 levels of
RFA were requested, which exceeds the utilization limits. Only 2 levels of RFA can be treated at one time.
Therefore, 2 levels would be considered medically reasonable and necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 2 levels of RFA have been met. Therefore, we decided that the Plan has to preapprove
2 levels of RFA.

We also decided that the Plan does not have to pre-approve 1 level of RFA.

The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is only covered under certain
medical indications.

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 services. Our physician
reviewer found that 3 levels of treatment exceed the utilization limits. Only 2 levels of RFA can be treated at
one time. Therefore, additional levels would be considered medically reasonable and necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 1 level of RFA have not been met. Therefore, we decided that the Plan does not
have to pre-approve 1 level of RFA.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
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 you need help with a walker. The Plan denied your request. The Plan says your needs do not require an interdisciplinary team approach to delivery of rehab 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 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 physician reviewer found that you were admitted to the acute care hospital for fractures of ribs, sternum and T-10 vertebrae, after a motor vehicle collision. Your medical problems are stable. There are no complex nursing needs. You do not require treatment by multiple therapies in an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided from December 5, 2020, through December 11, 2020.

You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says authorization was not obtained.

The Plan contract says that outpatient rehabilitation services are covered, and prior authorization is required after 12 visits.

We looked at the file and the Plan's rules. The file shows that authorization was not obtained. Therefore, we decided that the Plan does not have to pay for physical therapy services provided from December 5, 2020, through December 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz Fx (J7321).
You asked the Plan to pre-approve Supartz Fx. You say that the requested drug is necessary. The Plan denied your request. The Plan says there is no indication that the enrollee tried and failed the preferred drugs.
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 Supartz Fx. Our reviewer says that the requested drug, Supartz Fx, is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has tried and failed the required drugs. The reviewer found that there is no documentation provided indicating that the Plan's required drugs likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the requested drug, Supartz Fx, is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz Fx have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz Fx (J7321).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) imaging, skull base to mid-thigh.

You asked the Plan to pre-approve a PET/CT scan, skull base to mid-thigh. You say that this request is medically necessary for your medical condition. The Plan denied your request. The Plan says that at this time, there is no medical need for the requested imaging services.

The Plan must follow Medicare rules. Medicare rules say that PET 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 a PET/CT scan, skull base to mid-thigh. Our reviewer says that the requested service is medically necessary and reasonable. Our physician reviewer found that you are 61-year-old male with squamous cell carcinoma of the anus. You have been on immunotherapy with Novilumab and responding well. You have been receiving PET scans to monitor for metabolic activity of his cancer every 6 months. It is medically necessary to closely monitor your carcinoma for any reactivation of his carcinoma especially given the stage of initial diagnosis having been advanced. It is therefore acceptable to have PET/CT scans done routinely every 6 months as 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 a PET/CT scan, skull base to mid-thigh have been met. Therefore, we decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) imaging, skull base to mid-thigh.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) service provided from October 7, 2020, to November 5, 2020.

You asked the Plan to pay for the SNF services. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says up to 100 days each benefit period for inpatient services in a SNF. The Plan also says that the 100-day SNF benefit has been exhausted.

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 July 17, 2020, to February 14, 2021. 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 Plan does not have to pay for the skilled nursing facility (SNF) service provided from October 7, 2020, to November 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive cardiovascular panel provided on November 13, 2020.
You asked the Plan to pay for the testing services. You say that the lab performed the services that were specifically requested by the enrollee's physician. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.
We looked at the file and the rules. In this case, the records do not indicate the testing was ordered for a specific medical problem. The test at issue was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the comprehensive cardiovascular panel provided on November 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration (20939).

You asked the Plan to pre-approve bone marrow aspiration. You say that this service is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery has not been demonstrated in peer-reviewed literature

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 bone marrow aspiration. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspiration remains experimental in cases of spinal fusion surgery. More research is needed to show safety and efficacy. Iliac crest autograft is the gold standard bone graft material.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration (20939).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311) for a power
wheelchair.
You asked the Plan to pre-approve an electronic connection. You say that the requested feature is a medical
necessity for the enrollee. The Plan denied your request. The Plan says the request is not necessary because
there is no documented need to control power options through the joystick.
The Plan follows Medicare rules. Medicare rules say that an electronic connection allows the enrollee to
control two or more motors from a single interface.
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 an electronic connection. Our reviewer
says that the requested item is not medically necessary. Our physician reviewer found that the enrollee has
paraplegia from non-traumatic spinal cord injury due to multiple sclerosis/transverse myelitis. The
documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., miniproportional
or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices
(e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators
through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g.,
control of an augmentative speech device or computer through the chair's drive control), or an attendant
control. The enrollee's strength and function in the upper extremities with the ability to feed, groom, and dress
and perform intermittent catheterization indicates that the enrollee can control any power options through their
own individual switches.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an electronic connection have not been met. Therefore, we decided that the Plan
does not have to pre-approve an electronic connection (E2311) for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the contact lens fitting (92310) provided February 8, 2021.

You asked the Plan to pay for the contact lens fitting. You say that the contact lenses are not cosmetic and there should be no fee for the fitting. The Plan denied your request. The Plan says the charges were assessed appropriately, and you are responsible for a contact lens fitting fee.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file and the Plan's rules. Though the Plan offers a vision benefit in excess of Medicare coverage, the contact lens fitting is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the contact lens fitting (92310) provided February 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid (V5298) received December 8, 2020 from the non-participating vendor.

You asked the Plan to pay for the hearing aid. You say that you needed to obtain hearing aids that were hypoallergenic. The Plan denied your request. The Plan says hearing aids ordered through providers other than Plan-participating vendors are not covered.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan pays for hearing aids only when ordered through Plan-participating vendors. 

We looked at this physician's review, the file, and the Plan's rules. The provider in this case is not part of the Plan's hearing services network. Based on this information, we decided that the Plan's rules for coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid (V5298) received December 8, 2020 from the non-participating vendor.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for probiotics purchased on January 31, 2021.

You asked the Plan to reimburse you for the probiotics. You say that probiotics are recommended by your doctor. The Plan denied your request. The Plan says under the Pick Your Perks reimbursement program probiotics are not covered.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the probiotics are an OTC item. The Plan pays for OTC items, but probiotics are not covered. Therefore, we decided that the Plan does not have to reimburse you for probiotics purchased on January 31, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service and ground mileage provided on October 14, 2020.

You asked the Plan to pay for the ambulance service and ground mileage. You say that the diagnosis is not related to hospice, and the trip is not related to hospice care. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ambulance service and ground mileage provided on October 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on December 2, 2020.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit 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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on March 19, 2020, and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on December 2, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the Covid testing provided on November 22, 2020.

You asked the Plan to pay for the testing services. You say that you need to be reimbursed. The Plan denied your request. The Plan says the test was not rendered because of possible exposure or symptoms.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The records do not show that the testing was ordered due to signs or symptoms of disease. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the Covid testing provided on November 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital admission for a lumbar laminectomy.

You asked the Plan to pre-approve acute inpatient hospital admission. You say that this is medically necessary. The Plan denied your request. The Plan says it is not expected that you will need to stay at least two midnights.

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 pre-approve acute inpatient hospital admission. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found the records show that you are medically stable and have been provided medical clearance to undergo this elective procedure. The planned procedure is not classified as an Inpatient Only procedure. The lumbar laminectomy is currently approved as an ambulatory outpatient procedure. There is no documentation provided to support the expectation you will require a stay that lasts more than two 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 acute inpatient hospital admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital admission for a lumbar laminectomy.