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

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic obstructive pulmonary disease (COPD) with chronic hypercarbic and hypoxic respiratory failure. There is no evidence that she has tried and failed use of a bi-level positive airway pressure (BiPAP) device. The criteria for coverage are not met and the home ventilator is therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve both contact lenses and eyeglasses.
You asked the Plan to pre-approve both types of vision aids. You say that contact lenses are medically necessary to wear with eyeglasses as you suffer from degenerative myopia. The Plan denied your request. The Plan says the vision benefit covers either one pair of glasses or contact lenses per calendar year.
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. Your Plan only offers coverage of either one pair of eyeglasses or one pair of contact lenses, up to a $200 annual allowance. Although using both of these items may be appropriate for you, neither Medicare nor your health plan offer coverage for this.
Based on this information, we decided that the Plan's rules for coverage of contact lenses and eyeglasses have not been met. Therefore, we decided that the Plan does not have to pre-approve both contact lenses and eyeglasses.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on September 11,
2019.
You asked the Plan to pay for the physical therapy services. You say that the enrollee needed medical services
due to right sided weakness with altered mobility. The Plan denied your request. The Plan says the services
were not necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 physical therapy services. Our physician
reviewer found that the enrollee has neuropathy, muscle weakness, and rheumatoid arthritis. The enrollee was
evaluated by a physical therapy assistant and found to be at minimal assist for bed mobility, max assist for sitto-
stand, moderate assist for bed to wheelchair transfers, and minimal assist for tub/shower transfers. The
evaluation by a physical therapy assistant is not per Medicare guidelines. For these reasons, the requested
therapy date of service cannot be accepted as specific and effective therapy for the enrollee's 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 the physical therapy services have not been met. Therefore, we decided that the
Plan does not have to pay for the physical therapy services provided on September 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power mobility scooter (E1399).
You asked the Plan to pre-approve a power scooter. You say that you need to get around your home and
apartment building. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 power scooter. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found this enrollee has a personal mobility deficit but it is not clear that it impairs participation in
MRADLs as the documentation notes she can manage her personal care independently currently. The
documentation indicates she is able to use a cane and there is no evidence of failed use of a walker or manual
wheelchair. There is no evidence of a detailed home evaluation indicating she is able to safely operate her PMD
in the home.
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 power scooter have not been met. Therefore, we decided that the Plan does
not have to pre-approve the power mobility scooter (E1399).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One (J7325) injections.You asked the Plan to pre-approve Synvisc-One. You say that the Synvisc-One is medically necessary.The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered.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 Synvisc-One. Our reviewer says that coverage criteria is not met. Our physician reviewer found the enrollee did not trial the plan preferred drugs. The records do not show that the plan preferred drugs would be less effective or unsafe 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 Synvisc-One have not been met.Therefore, we decided that the Plan does not have to pre-approveSynvisc-One (J7325) injections.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET/CT scan of the body.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your
request. The Plan says the requested study would exceed the allowed limit of three scans for this cancer type.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered up to three times in a
lifetime.
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 scan. Our reviewer says that the
requested scan is not medically reasonable or necessary. Our physician reviewer found the most recent PET/CT
report referenced comparison PET/CT scans on 3/13/19 and 9/5/19 and 12/14/19. The number of PET/CT
scans certainly exceeds the CMS guideline limit of 3 scans per diagnosis.
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 scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve PET/CT scan of the body.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve semi-electric hospital bed (E0295) mattress (E0271) and side bed rails (E0305).
You asked the Plan to pre-approve semi-electric hospital bed. You say that the enrollee disagrees with the denial as his doctors have stated he have plentiful reasons for getting a hospital bed with rails as well as adjustable head and feet. The Plan denied your request. The Plan says a semi-electric hospital bed is not medically necessary.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 semi-electric hospital bed. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's condition does not require positioning of the body in ways not feasible in an ordinary bed. The documentation does not support frequent or immediate changes in body position. The enrollee's condition does not need special attachments that cannot be fixed and used on an ordinary bed. A semi-electric bed is not medically necessary for this enrollee per the documentation including the DME consulting evaluation on 9/25/19 which indicates that the enrollee's needs can be safely and effectively met without a semi-electric hospital bed 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 semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve semi-electric hospital bed (E0295) mattress (E0271) and side bed rails (E0305).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cyproheptadine tablets.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says self-administered drugs are not covered.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Cyproheptadine tablets.Benefits for these services may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for digital analysis of electroencephalogram (EEG) (CPT 95957) provided to the enrollee on December 16, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the submitted documentation indicates the video EEG monitoring was normal and does not include documentation that clearly reflects why the digital analysis was needed.
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 95957 is "digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis)." We asked our coding 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found the medical records provided does not include documentation indicates that the EEG was normal. There is no documentation that indicates why the digital analysis needed to be performed, therefore it is inappropriate to use CPT 95957 when there are no spikes to analyze. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for digital analysis of electroencephalogram (EEG) (CPT 95957) provided to the enrollee on December 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on January 10,
2018.
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the durable medical
equipment provided on January 10, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Granix for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is not the preferred step therapy drug.
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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found there is no evidence of a trial and failure of Neupogen and Nivestym. The documentation does not support that Neupogen (filgrastim) and Nivestym (filgrastim-aafi) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.
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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Granix for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ynvisc injection for the enrollee.You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says the plan's preferred visco supplements are Orthovisc and Monovisc and don't require prior authorization.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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found there is no evidence of a trial and failure of Orthovisc and Monovisc. The documentation does not support that Monovisc and Orthovisc (Hyaluronic acid) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 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 drug have not been met.Therefore, we decided that the Plan does not have to pre-approve ynvisc injection for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for
coverage of a LTACH admission.
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 is currently undergoing treatment at an acute care hospital (ACH),
having been admitted with bacteremia. The enrollee is intubated/ventilated. He subsequently received a
tracheotomy and is tolerating being on a tracheotomy collar. There is no evidence that the enrollee requires
services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care,
there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH
until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level
of care for any ongoing long term care needs.
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 long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued physical therapy (PT).
You asked the Plan to pre-approve these services. You say that the services are medically necessary to improve your mobility. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the submitted records show that you have been seen for 10 follow up PT visits in the past 45 days and continue to have constant dizziness. The dizziness is worse with position changes and walking. The records note that you are to continue your current home exercise program. The requested therapy is not accepted as specific and effective therapy for your condition. You are able to perform a home exercise program. Your functional level does not require the unique skills of a professional therapist to safely and effectively provide treatment. The services are not part of a maintenance program and are not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued physical therapy (PT).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vectibix injection for the enrollee.You asked the Plan to pre-approve the injection. You say that this is medically necessary.The Plan denied your request. The Plan says the requirement is: test results show tumor cells do not have KRAS or NRAS mutations.The Plan must follow Medicare rules. The rules say that Medicare pays fora 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 the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the use of Vectibix is approved and supported only for patients whose colon cancer expresses wild-type KRAS. The enrollee has a KRAS mutation and therefore her tumor is not wild-type. The documentation does not support that the requested use is medically reasonable and necessary, nor that it is safe and effective 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 the injection have not been met.Therefore, we decided that the Plan does not have to pre-approve Vectibix injection for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for speech therapy provided from November 1,
2019 through November 29, 2019.
You asked the Plan to waive the copayment for speech therapy. You say that the provider ordered speech
therapy when only ear wax needed to be removed. You say that there shouldn't be a $300 copayment. The Plan
denied your request. The Plan says the copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The contract with the Plan clearly says that you must pay a $25
copayment for Medicare covered speech therapy services.
The enrollee has been asked to pay a $25 copayment for each speech therapy visit. The total amount owed is
$300 ($25/visit x 12 visits = $300). Speech therapy falls within the "Outpatient rehabilitation services" benefit
category. This means that the enrollee has been asked to pay the correct amount based on the 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 speech therapy provided from November 1,
2019 through November 29, 2019.