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

We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and one power seating system motor (E2310).
You asked the Plan to pre-approve the upgraded electronics. You say that you have muscle spasms and have had repeated strokes that you have left you with a limp when walking so you cannot walk to far without falling down and you request reconsideration for the chair. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for this electric accessory. The approved power option comes with its own switches.
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 the upgraded electronics. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a mobility limitation that cannot be resolved with use of standard mobility aids including a manual wheelchair due to her bilateral upper extremity strength limitations. However, she has symmetrical upper extremity antigravity strength and if she is able to operate the joystick controller for the wheelchair drive she should be able to operate additional features with the standard switches supplied. For these reasons she does not meet criteria for the electronic controller connection being requested.
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 upgraded electronics have not been met. Therefore, we decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and one power seating system motor (E2310).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from June 5, 2019 to June 22, 2019.You asked the Plan to pay for home health services. You say that you would like the Plan to reconsider their of payment.The Plan denied your request. The Plan says the claim will be paid once a corrected claim is received.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, a valid 18 digit alphanumeric treatment authorization code, a correct type of bill and a valid 5 digit CBSA code must be correct on the claim.Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from June 5, 2019 to June 22, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vasopneumatic therapy.
You asked the Plan to pre-approve these services. You say that you have been referred for these services to treat neuropathy. The Plan denied your request. The Plan says the services are not covered for your condition.
The Plan must follow Medicare rules. Medicare rules say that vasopneumatic therapy may be covered for the treatment of edema. We looked at the file and Medicare rules. The file shows that the services are being requested to treat neuropathy. There is no documentation of edema. 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 vasopneumatic therapy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Soliris.You asked the Plan to pre-approve Soliris. You say that the medication is 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. 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 Soliris. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the enrollee is noted to have sero-positive myasthenia gravis (MG). The documentation confusingly indicates that the enrollee's symptoms are resolved and improved, while simultaneously stable to slightly worse. The enrollee apparently responded well to intravenous immunoglobulin (IVIG), but is precluded from further treatment with the drug after developing a blood clot while receiving the drug. The enrollee is taking steroids, but he does not like the side effects. The documentation references two prior cycles of an unnamed drug in October and November of an unnamed year. It is unclear if this is a reference to prior IVIG use or prior azathioprine use. There is no clear documentation of how the enrollee responded to azathioprine, assuming he received it previously or after March 17, 2020. There is no indication that the enrollee has received a meningococcal vaccine. As such, the current documentation is insufficient to show that the requested eculizimab is medically necessary, reasonable or safe.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Soliris have not been met.Therefore, we decided that the Plan does not have to pre-approve Soliris.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee on November 20, 2019.
You asked the Plan to pay for the orthoses and sleeves. You say that the claim should be paid. The Plan denied your request. The Plan says the medical records do not support this service.
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 orthoses and sleeves. Our reviewer says that the enrollee does not meet criteria for the orthoses and sleeves ordered. Our physician reviewer found the prescribing physician ordered bilateral knee orthoses with suspension sleeves, as well as bilateral ankle/foot orthoses. The documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is no objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 orthoses and sleeves have not been met. Therefore, we decided that the Plan does not have to pay for bilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee on November 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Foresee Home Visual Assessment (0379T).You asked the Plan to pre-approvethe visual assessment. You say that the Foresee Home is medically necessary and a covered service.The Plan denied your request. The Plan says the item is not a covered service.The Plan must follow Medicare rules. Medicare rules say that services determined to be medically unnecessary are not covered.We looked at the file and Medicare rules. Medicare rules consider the item at issue to be not medically necessary and non-covered.  Based on this information, we decided that Medicare rules for coverage of the visual assessment have not been met.Therefore, we decided that the Plan does not have to pre-approvea Foresee Home Visual Assessment (0379T)
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from September 3, 2019 to September 19, 2019.You asked the Plan to pay for the home health services. You say that this is not an episodic claim. This must be processed as a per visit claim.The Plan denied your request. The Plan says the TOB used is not valid in this case.The Plan must follow Medicare rules. Medicare rules say that there are certain TOBs used for home health RAPs and claims. In this case, the TOB used is 0324. This is not a valid TOB for home health claims, either in plan of care or without a plan of care.Therefore, we decided that the Plan does not have to pay for the home health services provided from September 3, 2019 to September 19, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from November 9, 2019 through November 11, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. The hospital services November 9, 2019 through November 11, 2019 were medically necessary and reasonable. 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 care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from November 9, 2019 through November 11, 2019.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forincision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator (CPT Code 64568).You asked the Plan to pay forthe services. You say that you are requesting review of denial of services.The Plan denied your request. The Plan says the Medicare rules have not been met. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.Your records show you have sleep apnea, you are unable to tolerate a CPAP and mask, and that a dental appliance did not work for you. The record sent by your provider indicates the Inspire hypoglossal nerve stimulator is appropriate option and that this device will likely benefit your condition. Medicare guidelines state that 0466T Insertion of chest wall respiratory sensor electrode is not a covered benefit for the State of North Carolina. Furthermore, the Medicare BenefitPolicy Manual, Chapter 16, states that that services related to non-covered services are not covered services under Medicare. Therefore, 64568 is noncovered when requested in conjunction with the non-covered code 0466T. Under Medicare guidelines, your request is not a covered benefit in the State of North Carolina. 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 forincision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator (CPT Code 64568).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental oral exam (D0120) provided on December 4, 2019.
You asked the Plan to pay for the dental services. You say that you believe the oral exam should be covered because the dental office did not inform you beforehand that they were going to be performing the exam. The Plan denied your request. The Plan says you were not eligible for this exam.
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. You exhausted your benefit because you had oral exams performed on June 14, 2019 and October 14, 2019. Therefore, we decided that the Plan does not have to pay for dental oral exam (D0120) provided on December 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments.
You asked the Plan to pre-approve the approve a debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments. The Plan denied your request. The Plan says you do not meet the criteria established to receive the debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments for 2020.
The Plan contract says that, in order to be eligible for an allowance, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. We looked at the file and the Plan's rules. The file shows that your medical conditions are not eligible medical conditions under the Plan's debit card allowance benefit. Therefore, we decided that the Plan does not have to pre-approve a debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the audiology services provided on November 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the audiology services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the audiology services provided on November 19, 2019 by an out of network (OON) provider.
Your complaint about contacting the Plan to find an in-network audiologist is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care provided from November 12, 2019 to November 14, 2019.
You asked the Plan to pay for the physician services. You say that the enrollee was not enrolled in hospice at the time the services were provided, per the print out. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on November 1, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the initial hospital care provided from November 12, 2019 to November 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from November 23,
2019 through November 27, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your
cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim
was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file shows that you received emergency care on November 23, 2019 and then you were admitted
for inpatient hospital care on November 23, 2019 and discharged on November 27, 2019. You are asked to pay
a $90 copayment for the emergency care. You were asked to pay a $250 copayment per day from November
23, 2019 through November 26, 2019, days 1-4 of your inpatient hospital care. You were discharged on
November 27, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a
$250 copayment per day required for days 1-6 and a $90 copayment per visit for emergency care. Copayment
is not waived for emergency care if admitted to inpatient hospital. 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 inpatient hospital care from November 23, 2019 through November 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a LINX procedure.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 covered.The Plan must follow Medicare rules. The rules say that procedure codes 43284 and 43285 are non-covered.We looked at the file and Medicare rules. The services at issue are a LINX procedure described by codes 43284 and 43285. These codes are denied by Medicare as non-covered.Therefore, we decided that the Plan does not have to pre-approve a LINX procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for endovenous ablation.
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 available from 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 a referral to an out-of-network provider for endovenous ablation.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve esophagogastroduodenoscopy.
You asked the Plan to pre-approve esophagogastroduodenoscopy. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically
necessary.
The Plan follows Medicare rules. Medicare rules say that esophagogastroduodenoscopy is only covered for
certain 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 esophagogastroduodenoscopy. Our
reviewer says that the documentation does not support that the requested esophagogastroduodenoscopy is
medically reasonable or necessary. Our physician reviewer found an earlier MRA showed celiac artery
occlusion, large splenic varices, slenorenal shunt. No esophageal or gastric varices were identified at the time
of the March 13, 2018 EGD which showed only "mild portal hypertensive gastropathy." The enrollee is not
anemic nor are the red cells microcytic (hemoglobin 12.5 with MCV 94.3 on 1/23/2020), the enrollee has
declined consideration of liver transplantation, nor do available records support concern for active GI
hemorrhage -- e.g. only a small amount of blood tinged sputum with coughing has been reported for which a
chest x-ray was ordered (results not provided). Therefore, the enrollee does not meet criteria for the requested
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 esophagogastroduodenoscopy have not been met. Therefore, we decided that
the Plan does not have to pre-approve esophagogastroduodenoscopy.