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

We decided that the Plan does not have to pre-approve a non-expandable controller (CPT E2375) and an adjustable angle foot plate (CPT K0040).You asked the Plan to pre-approve CPT codes E2375 and K0040. You say that  The Plan denied your request. The Plan says the accessories which remain denied are not covered by Medicare because they are already included with the payment for K0838.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that you have been pre-approved for coverage of CPT code K0838. Medicare rules state that payment for CPT codes E2375 and K0040 is included in the allowance for CPT codeK0838. Therefore, we decided that the Plan does not have to pre-approve separate payment for a non-expandable controller (CPT E2375) and an adjustable angle foot plate (CPT K0040).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that these services are medically necessary.The Plan denied your request. The Plan says that there is no advantage in transferring the enrollee from the current acute care hospital to an LTACH.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. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found you are generally medically stable and the documentation does not support that you
have complex medical issues that require acute rehab nursing care, or monitoring by an inpatient physical,
medicine and rehabilitation (PMR) physician three times per week. While you may well benefit from
continuing physical therapy (PT) and occupational therapy (OT), the documentation does not support that there
is need for an intensive therapy program with therapy 3 hours per day, with frequent physician oversight and an
interdisciplinary approach to rehabilitation 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OPDIVO (J9299) and Ipilimumab (J9228).
You asked the Plan to pre-approve OPDIVO and Ipilimumab. You say that the requested medications are necessary. The Plan denied your request. The Plan says based on the documentation provided, 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 OPDIVO and Ipilimumab. Our reviewer says that the medications are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of metastatic non-small cell lung cancer. The enrollee has received previous treatment with cisplatin/paclitaxel/pembrolizumab, ramucirumab/docetaxel, and pembrolizumab. The enrollee has documented disease progression on these regimens. OPDIVO is similar class and mechanism of action as pembrolizumab. Compendia does not support the use of similar immunotherapeutic agent following demonstrated disease progression with similar agent. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of OPDIVO and Ipilimumab have not been met. Therefore, we decided that the Plan does not have to pre-approve OPDIVO (J9299) and Ipilimumab (J9228).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.You asked the Plan to pre-approve a semi-electric hospital bed. You say that your heels are sore and your feet need to be elevated to offload pressure.The Plan denied your request. The Plan says that there is no documentation provided from your doctor that explains why you need a semi-electric hospital bed.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; or2. Requires attachments which can only be attached to a hospital bed; AND3. 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 a semi-electric hospital bed. Our reviewer says that a semi-electric hospital bed is not medically reasonable and necessary in this case. There is no documentation that your condition requires position of the body in ways not feasible in an ordinary bed. There is no documentation that you require frequent changes in body position or that there will be a need for immediate changes in body position. There is no documentation that your condition requires special attachments that cannot be fixed and used on an ordinary bed. Our physician reviewer found that your condition does not meet Medicare criteria for a semi-electric hospital bed.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 semi-electric hospital bed have not been met.Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power-operated vehicle (POV)/scooter.
You asked the Plan to pre-approve the Group 2 POV. You say that this device is necessary for the enrollee to
be able to be mobile. The Plan denied your request. The Plan says this type of POV is not covered by Medicare
as it has features which are not required for use in the home.
The Plan must follow Medicare rules. Medicare rules say that Group 2 POVs have added capabilities that are
not needed for use in the home and are noncovered.
Although this POV may be appropriate for the enrollee, neither Medicare nor the Plan offers coverage for this
item. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power-operated vehicle
(POV)/scooter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the thoracic spine and an MRI of the lumbar spine.
You asked the Plan to pre-approve the MRIs. The Plan denied your request. The Plan says the MRIs are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRIs. Our reviewer says that the requested MRIs are not medically reasonable and necessary for the enrollee in this case. Our physician reviewer found that the records provided for review were primarily limited to the results of physical therapy sessions. There were no examination notes provided for review, nor was there an adequate description of the enrollee's condition, nor any indication from the enrollee's physician(s) as to why the imaging studies had been requested. In the absence of such relevant clinical information, it cannot be determined that the requested MRIs are 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 the MRIs have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI of the thoracic spine and an MRI of the lumbar spine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe allergy injection provided on January 29, 2020.You asked the Plan to waive the copayment forthe allergy injection. You say that you have not been charged a copayment for allergy shots prior to 2020. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment per visit to a specialist. For this date of service, you have been asked to pay the allowed amount of the claim because this amountis less than the $20 copayment for the allergy injection.You have been asked to pay a $8.98 copayment for the allergy injection. The allergy injection falls within the "Physician/Practitioner services, including doctor's office visits" benefit category.The record shows the allergy injection is a physician service.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 forthe allergy injection provided on January 29, 2020.Our decision is only about the January 29, 2020 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar fusion arthrodesis.
You asked the Plan to pre-approve lumbar fusion arthrodesis. You say that the requested lumbar fusion
arthrodesis is medically necessary. The Plan denied your request. The Plan says the requested lumbar fusion
arthrodesis is not medically necessary.
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 lumbar fusion arthrodesis. Our reviewer
says that the requested lumbar fusion arthrodesis is not medically necessary. Our physician reviewer found this
enrollee presents with chronic low back pain with intermittent radiating into the right leg to the knee with
intermittent giving out. Functional limitations are noted in sitting, standing, and walking tolerances. Clinical
exam findings have documented right knee clinical findings consistent with imaging evidence of mild to
moderate tricompartmental degeneration. Clinical findings have not documented a focal neurologic deficit or
positive nerve tension signs. There is imaging evidence of L4/5 disc bulge with spondylosis and mild to
moderate bilateral central canal, lateral recess, and foraminal narrowing. There is reported radiographic
evidence of significant disc space narrowing degeneration at L4/5 with a subtle degenerative spondylolisthesis.
Electrodiagnostic study reportedly did not demonstrate radiculopathy. He has failed to achieve adequate
improvement with recent conservative treatment, including activity modification, medications, and facet
injections. Under consideration is a request for L4/5 anterior lumbar interbody fusion. Current evidence based
medical literature would not fully support lumbar fusion surgery at this time. There is no radiographic evidence
of spondylolisthesis or spinal segmental instability on flexion and extension x-rays. There is no discussion
supporting the need for wide decompression that would result in temporary intraoperative instability and
necessitate fusion. There is no documentation of a focal neurologic deficit or signs/symptoms of significant
neurogenic claudication. There is no evidence that other pain generators or sources of dysfunction have been
fully ruled-out with additional imaging reported to be pending. Therefore, this request for lumbar fusion
arthrodesis is not 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 lumbar fusion arthrodesis have not been met. Therefore, we decided that the
Plan does not have to pre-approve lumbar fusion arthrodesis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedental implant services.You asked the Plan to pre-approvethe dental implant services. You say that the enrollee is status post multiple surgeries to remove squamous cell carcinoma of the oral cavity. You say that the enrollee currently has significant oral defect, which prevents him from functioning, eating, and talking. Yousay that the prosthetic rehabilitation outlined in the letter is medically necessary to restore form and function, as well as to alleviate the enrollee's severe depression. You say that the requested services will allow the enrollee to have appropriate nutritional intake so that chewing his food will be possible.The Plan denied your request. The Plan says neither Medicare nor the enrollee's Plan covers the requested services.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approvedental implant services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient rehabilitation facility (IRF) care.You asked the Plan to pre-approve the IRF services. You say that the services are medically necessary.The Plan denied your request. The Plan says that coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The documentation provided to the IRE by the health plan was limited to a background data form. No copy of the plan denial was provided and no medical records were forwarded to the IRE for clinical review.Therefore, we decided that the Plan has to pre-approve inpatient rehabilitation facility (IRF) care.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 pre-approve a stationary bike and elliptical.
You asked the Plan to pre-approve a stationary bike and elliptical. You say that you have been going to the gym for almost 20 years. You are both 71 and are at high risk for COVID-19. You could put both machines in your garage so you could safely exercise. The Plan denied your request. The Plan says the requested items are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a stationary bike and elliptical.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the oximeter device, non-invasive (E0445).
You asked the Plan to pre-approve the oximeter device. You say that this device was recommended by her primary doctor and is necessary for her health and you do not understand how Medicare can reject this request. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that oximeters are not covered because they are monitoring devices that provide information to the treating practitioner to assist in managing the beneficiary's treatment. While an oximeter may be appropriate in this case, neither the Plan nor Medicare offers coverage of this device. Therefore, we decided that the Plan does not have to pre-approve the oximeter device, non-invasive (E0445).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelaparoscopic tubal ligation.You asked the Plan to pre-approvethese services. You say that the enrollee does not want to have children.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that tubal ligation forthe purpose of sterilization is non-covered.We looked at the file and Medicare rules. The services at issue are tubal ligation for sterilization. This procedure is not covered by Medicare.Therefore, we decided that the Plan does not have to pre-approvelaparoscopic tubal ligation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on March 30, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 did not pre-approve the laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on March 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine toenail clipping.
You asked the Plan to pre-approve the toenail clipping services. You say that you are 70 years old and cannot
cut your own toenails any longer. You feel that the plan should cover this as your caregiver is not able to do
this for you. The Plan denied your request. The Plan says this is not a Medicare covered service since you do
not have any conditions for which it could be allowed.
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or
feet or have fungal nails.
Records do not show that any of these conditions are present. The services you are asking the Plan to preapprove
are routine foot care services. Based on this information, we decided that Medicare rules for coverage
of the toenail clipping services have not been met. Therefore, we decided that the Plan does not have to preapprove
routine toenail clipping.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on December 23, 2019.
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 services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare
and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does
not have to pay for the home infusion therapy rendered on December 23, 2019.
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.