Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 the health plan's denial of LTACH coverage should be upheld. The enrollee is currently undergoing treatment at an ACH for intracranial bleeding. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee remains on a ventilator. It is not clear that ventilator liberation or decannulation are expected. 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 LTC 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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an endoscopic spinal decompression (62380).
You asked the Plan to pre-approve the endoscopic spinal decompression. You say that the procedure is medically necessary. The Plan denied your request. The Plan says endoscopic decompression is investigational and is non-covered.
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 endoscopic spinal decompression. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the endoscopic decompression procedure remains experimental at this time. More research is needed to show safety and efficacy. Open laminectomy remains the gold standard for laminectomy decompression. 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 endoscopic spinal decompression have not been met. Therefore, we decided that the Plan does not have to pre-approve an endoscopic spinal decompression (62380).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fabric clothing protectors for a wheelchair.
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 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. Therefore, we decided that the Plan does not have to pre-approve fabric clothing protectors for a wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Myfortic.
You asked the Plan to pre-approve a tier exception for Myfortic. You say that the exception is needed. The Plan denied your request. The Plan says Part B medications do not qualify for tier exceptions.
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a tier exception for Myfortic have not been met. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Myfortic.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for impression and custom preparation; oral surgical splint services (CPT code 21085).
You asked the Plan to pay for the services. You say that the services are necessary because it was part of the surgery for cancer in your mouth where the bone, and teeth were removed last July. The Plan denied your request. The Plan says very little clinical information was received about your illness. The Plan states your records show a diagnosis given to the plan by your provider as personal history of malignant neoplasm of bone. The Plan states additional information was requested but not received, and in order to approve the services requested, the plan needs more information, such as your doctors' notes, x-rays, and lab tests.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 21085 is not supported in the medical record. Specifically, insufficient information was provided, and the information sent cannot verify if the services are considered necessary. 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 impression and custom preparation; oral surgical splint services (CPT code 21085).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed and trapeze bar (E0910,
E0265).
You asked the Plan to pre-approve a total electric hospital bed and trapeze bar. You say that the hospital bed is
medically necessary. The Plan denied your request. The Plan says total electric hospital beds are non-covered.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers
coverage for this item. Since the hospital bed is non-covered, the trapeze bar feature cannot be approved.
Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed and trapeze bar
(E0910, E0265).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).

You asked the Plan to pre-approve this item. You say that a total electric hospital bed is medically necessary. The Plan denied your request. The Plan says a total electric hospital bed is not a covered benefit under your contractual policy or by Medicare.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 

While a total electric hospital bed may be appropriate for you in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided by an ineligible provider on November 27, 2020.
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 provider is ineligible to bill Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided by an ineligible provider on November 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6240) and two retainer crowns (D6750 x2).
You asked the Plan to pre-approve the pontic and retainer crowns. You say that these services should be covered under your dental insurance. The Plan denied your request. The Plan says these services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a pontic (D6240) and two retainer crowns (D6750 x2).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computerized corneal topography, unilateral or bilateral, with interpretation and report (CPT code 92025) provided to the enrollee on December 11, 2020, by a non-participating provider.
You asked the Plan to pre-approve the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is considered experimental and investigational.
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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the provider performed corneal topography on December 11, 2020. The clinical value and effectiveness of corneal topography in the setting of cataracts have not been demonstrated in the peer-reviewed literature. The review has determined that the services were not 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 the service have not been met. Therefore, we decided that the Plan does not have to pre-approve computerized corneal topography, unilateral or bilateral, with interpretation and report (CPT code 92025) provided to the enrollee on December 11, 2020, by a non-participating provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage and non-emergency transport provided on December 1, 2020.
You asked the Plan to pay for the transportation services. You say that the enrollee's hospice election was not made until after the transportation was provided. 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. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ground mileage and non-emergency transport provided on December 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pomalyst.

You asked the Plan to pre-approve Pomalyst. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.

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 Pomalyst.

Benefits for Pomalyst 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 long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH 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 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on May 12, 2021 with breathing problems and low blood oxygen levels. During this current hospital course, he has been treated with intravenous antibiotics and extra oxygen. There is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care facility. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower leg platform crutch substitute.

You asked the Plan to pre-approve the services. You say that this is medically necessary, as you will be unable to use crutches and will be in a cast for six weeks. The Plan denied your request. The Plan says this is not covered by Medicare.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that this device will be safe and effective for your 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a lower leg platform crutch substitute.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on August 17, 2020.

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 procedure code 99153 is not supported.

The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes. 

We looked at the file and Medicare rules. Billed procedure code 99153 (moderate sedation services) has a PC/TC indicator of 3 and no separate PC payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered on August 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
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 enrollee does not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met. We looked at the file and Medicare rules. The records show that the enrollee is not treated with insulin. 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 Freestyle Libre continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
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 enrollee does not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met. We looked at the file and Medicare rules. The records show that the enrollee is not insulin-treated with three or more daily injections. 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 Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on December 11, 2020.
You asked the Plan to waive the copayment for lab work. You say that you have never had to pay for this before. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $10 copayment for outpatient diagnostic tests/laboratory tests. You have been asked to pay $8.93 which is less than your copayment amount of $10 for lab work. The correct copayment has been applied to the services that were provided. Lab work falls within the outpatient diagnostic tests/laboratory tests benefit category. 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 lab work provided by a participating provider on December 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept spinal ablation procedure (C9753, 22899,
C9752).
You asked the Plan to pre-approve the Intracept procedure. You say that the services are medically necessary.
The Plan denied your request. The Plan says this procedure is investigational and is not covered.
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 Intracept procedure. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and
efficacy of the Intracept procedure for back pain.
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 Intracept procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve an Intracept spinal ablation procedure (C9753, 22899, C9752).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extractions (CPT code D7999).
You asked the Plan to pre-approve the dental extractions. You say that your regular dentist cannot pull the teeth because there is not much to pull. You state your dentist feels you need to have this done surgically. The Plan denied your request. The Plan says this not covered by Medicare or your plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Review of the records show the surgical extractions are not to prepare the jaw for radiation and therefore, not covered. Medicare rules says that dental treatment, such as comprehensive dental care like surgical extractions is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve dental extractions (CPT code D7999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high strength lightweight manual wheelchair (K0004)
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says you can walk safely without an assistive device in the home.
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 wheelchair. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the lightweight wheelchair is being requested so it can be lifted into an SUV. According to Medicare a high strength lightweight wheelchair is covered when a beneficiary is able to self-propel the wheelchair while engaging in frequent activities in the home that cannot be performed in a standard wheelchair or the beneficiary requires a seat width, depth, or height that cannot be accommodated in a standard, light weight or hemi-wheelchair, and spends at least two hours per day in the wheelchair. A high strength lightweight wheelchair is rarely reasonable and necessary if the expected duration of need is less than three months. In this case, the documentation doesn't support that the you are unable to accomplish ADLs or mobility-related ADLs in the home. The medical necessity for the requested item is not met. 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a high strength lightweight manual wheelchair (K0004)