Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the eye exam and evaluation (92014) provided on
October 19, 2020.
You asked the Plan to waive the copayment for the eye exam and evaluation. You say that this was your annual
diabetic eye exam and should have no copayment. The Plan denied your request. The Plan says that physician
services have a $40 copayment when provided in-network.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that enrollees must pay a $0 copayment for an annual diabetic eye exam.
The Plan says you must pay a $40 copayment for the eye exam and evaluation. The Plan reached this decision
by assessing a copayment for physician services. Based on the Plan contract, however, you cannot be asked to
pay more than a $0 copayment for a diabetic eye exam, with a limit of one per year. The bill for this service
was submitted with diagnosis code E11.3533 (diabetes mellitus). There is no indication in the record that you
have had any other diabetic eye exams within the past year. The Plan has not submitted medical records from
the contracted provider for review. Without medical records, the copayment assessed cannot be verified.
Therefore, we decided that the Plan has to waive the copayment for the eye exam and evaluation (92014)
provided on October 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.

You asked the Plan to pre-approve the device. You say that you would like reconsideration because this device is medically necessary. The Plan denied your request. The Plan says this device is experimental.

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 device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this spacer device remains experimental as more research is needed to show its safety and efficacy. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the continuous glucose monitor. You say that the CGM is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin injections at least three times daily. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate.

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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested bone marrow aspirate remains experimental for use in spinal fusion surgery. More research is needed to show its safety and efficacy over the gold standard of an iliac crest bone graft. The services are not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation mileage.
You asked the Plan to provide an additional 66 miles. You say that you want to see your surgeon who is over
50 miles away. The Plan denied your request. The Plan says each one-way trip must not exceed 50 miles of
driving distance.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers routine transportation, and each one-way trip must not exceed 50 miles of driving
distance.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the
Plan does not have to provide additional routine transportation mileage.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a heavy-duty walker.

You asked the Plan to pay for a heavy-duty walker. You say that you would like reconsideration because your current walker is too small. The Plan denied your request. The Plan says you do not meet Medicare criteria for a Heavy-Duty Rollator.

The Plan must follow Medicare rules. Medicare rules say that a heavy-duty walker is covered for beneficiaries who weigh more than 300 pounds. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a heavy-duty walker have not been met. Specifically, the documentation submitted does not support that you weird more than 300 pounds. Therefore, we decided that the Plan does not have to pay for a heavy-duty walker.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the placement of a CardioMEMS system for the
enrollee.
You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The
Plan denied your request. The Plan says that this is not covered under the current Medicare Category B
Investigational Device Exemption Requirements.
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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. The efficacy of the
CardioMEMS heart failure system remains uncertain at this time. Further clinical study is needed to determine
the efficacy and safety of this device. Our physician reviewer found that the enrollee's condition does not meet
Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the placement of a CardioMEMS system for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lubiprostone.
You asked the Plan to pre-approve Lubiprostone. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Lubiprostone.
Benefits for Lubiprostone 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular stress test (93017) provided on June 26, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the stress test. You say that this service was medically necessary. The Plan denied your request. The Plan says they only cover out-of-network services in limited circumstances. The service provided was not pre-approved or urgent. Records show that the test was ordered on June 24, 2020, and was provided two days later. This service could have been provided in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 had network providers available who could have provided 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 cardiovascular stress test (93017) provided on June 26, 2020 by an out of network (OON) provider.
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 the stay is medically necessary. The Plan denied your request. The Plan says the stay is medically necessary.
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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for acute on chronic cholecystitis and was diagnosed with cholangiocarcinoma. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 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. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve YAG vitreolysis laser eye surgery.

You asked the Plan to pre-approve YAG vitreolysis laser eye surgery. You say that you would like reconsideration because this surgery is medically necessary. The Plan denied your request. The Plan says this surgery is experimental.

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 YAG vitreolysis laser eye surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a review of the literature and specialty society guidelines has not demonstrated sufficient data that this surgery is at least as efficacious as other available treatments.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of YAG vitreolysis laser eye surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve YAG vitreolysis laser eye surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided on September 9, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the orthosis was medically necessary for the enrollee. The Plan denied your request. The Plan says the provider did not discuss the need for the lumbar sacral orthosis with the enrollee.
The Plan follows Medicare rules. Medicare rules say that a spinal orthosis is covered when the criteria cited in the Medicare rules section is met. 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 lumbar-sacral orthosis. Our reviewer says that the requested orthosis was not medically reasonable and necessary. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient
documentation of a credible evaluation and a credible physical examination of the back. 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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided on September 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided August 12, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that this orthosis was medically necessary for the enrollee. The Plan denied your request. The Plan says there is no evidence that the prescribing physician saw the enrollee.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order. In this case, the physician order seems to request different orthoses then what was delivered to the enrollee. As the physician order does not match the proof of delivery, this request cannot be covered. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve epidural injections (62321).
You asked the Plan to pre-approve epidural injections. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that epidural injections are consider medically necessary only when an indication listed in the LCD is documented.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 epidural injections. Our reviewer says that the criteria for coverage of epidural injections have not been met. Our physician reviewer found there is no imaging or physical exam findings to support the performance of an epidural steroid injection. The request 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 epidural injections have not been met. Therefore, we decided that the Plan does not have to pre-approve epidural injections (62321).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Omeprazole.
You asked the Plan to pre-approve Omeprazole. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
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 Omeprazole.
Benefits for Omeprazole 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: 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 IRF care is needed over care provided at a skilled nursing facility. The Plan denied your request. The Plan says rules for IRF care have 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 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, the patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 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. Medically necessary care can be provided in a different level of care. Finally, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: 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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you were admitted to the hospital with COVID pneumonia with acute respiratory failure. You are unable to walk. You required moderate assistance for transfers. You required moderate to maximum assistance with activities of daily living. The documentation does not support that you require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that you require an intensive rehabilitation therapy program. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services exceed the enrollee's plan benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that once the enrollee has used their remainder of the 60 plan approved one-way trips, the enrollee will have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Otezla.

You asked the Plan to pre-approve Otezla. You say that Otezla therapy would provide significant clinical benefit for the enrollee. The Plan denied your request. The Plan says this medication does not fall under Part B.

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 Otezla.

Benefits for Otezla may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.