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

We decided that the Plan does not have to pre-approve an expandable controller (E2313, E2377, E2311) for a power wheelchair.

You asked the Plan to pre-approve the expandable controller. You say that the expandable controller is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when 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 expandable controller. Our reviewer says that the expandable controller is not medically necessary. Our physician reviewer found there is not a medical need to control the power options through the joystick. The enrollee is capable of using the standard switches to operate these features. 

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 expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2313, E2377, E2311) for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an apicoectomy (D3410) and a retrograde filling (D3430).

You asked the Plan to pre-approve the apicoectomy and retrograde filling. You say that you believe the apicoectomy and retrograde filling are the appropriate treatments for the enrollee. The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit package.

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 an apicoectomy (D3410) and a retrograde filling (D3430).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the one first intraoral periapical x-ray (D0220) and two additional intraoral periapical x-rays (D0230 x2), or pay more for the comprehensive periodontal evaluation (D0180), additional first intraoral periapical x-ray (D0220), bitewing x-rays (D0274), extractions (D7210), maxillary partial denture (D5213), and mandibular partial denture (D5214) provided by an OON provider.

You asked the Plan to pay for the first intraoral periapical x-ray and two additional intraoral periapical x-rays, and to pay more for the comprehensive periodontal evaluation, additional first intraoral periapical x-ray, bitewing x-rays, extractions, maxillary partial denture, and mandibular partial denture. You say that you would like these services to be covered. The Plan denied your request. The Plan says your intraoral x-rays benefit has been satisfied and the frequency limitation had been exceeded. The Plan also says that these services were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.

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, intraoral x-rays are limited to one procedure per calendar year. The record shows that you received two first intraoral periapical x-rays one of which was covered by the Plan, and your intraoral x-rays benefit had been exhausted. The contract also says that you are responsible for the difference between the billed amount and allowed amount for services received OON. The record also shows that you did not contact the Plan prior to these dates of service to verify benefits and provider eligibility. Therefore, we decided that the Plan does not have to pay for the one first intraoral periapical x-ray (D0220) and two additional intraoral periapical x-rays (D0230 x2), or pay more for the comprehensive periodontal evaluation (D0180), additional first intraoral periapical x-ray (D0220), bitewing x-rays (D0274), extractions (D7210), maxillary partial denture (D5213), and mandibular partial denture (D5214) provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay.

You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were admitted due to complications with surgery, and you cannot afford to pay this bill. The Plan denied your request. The Plan says you have been asked to pay 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 $200 copayment per day (per Medicare-covered stay), days 1-7, which includes day of admission and day of discharge.

You have been asked to pay a $200 copayment for the inpatient hospital stay. $200 x 7 = $1,400). The inpatient hospital stay falls within the "Inpatient hospital care" 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 the inpatient hospital stay.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Prolia injection.

You asked the Plan to waive the coinsurance for the Prolia injection. You say that you should not pay the extra $16 for the month when the authorization started in January. The Plan denied your request. The Plan says the coinsurance applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for each Medicare-covered Part B drug.

You have been asked to pay $263.43, which is 20% of the allowed amount for the Prolia injection. The allowed amount is $1,317.14 (20% x $1,317.14 = $263.43). The Prolia injection falls within the "Medicare Part B prescription drugs" 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 coinsurance for the Prolia injection.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy (PT) services.

You asked the Plan to waive the copayment for the PT services. You say that you were told Medicaid would
pay whatever Medicare would not pay. You received a statement from the provider and was shocked to learn
you owed over $500. The Plan denied your request. The Plan says the claim was processed, and the copayment
was applied correctly per the Evidence of Coverage.

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 $40
copay for Medicare covered physical therapy and speech therapy service.

You have been asked to pay $624.92 copay for the PT services. The PT services falls within the Outpatient
Rehabilitation Services 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 the physical
therapy (PT) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for take home supply of methadone.

You asked the Plan to pay for the take home supply of methadone. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 services at issue. 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 take home supply of methadone.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar facet injections with platelet-rich plasma.

You asked the Plan to pre-approve the requested services. You say that this is the best option for the enrollee's health. The Plan denied your request. The Plan says platelet rich plasma is only covered when the enrollee is in a clinical trial.

The Plan must follow Medicare rules. Medicare rules say that platelet-rich plasma is only covered under certain medical indications.

We looked at the file and Medicare rules. Platelet-rich plasma will be covered only for the treatment of chronic non-healing diabetic, venous and/or pressure wounds and only when the patient is enrolled in a clinical trial. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar facet injections with platelet-rich plasma.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for behavioral therapy for cardiovascular disease (G0446) and advance care planning (99497).

You asked the Plan to pay for the behavioral therapy and advance care planning. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the behavioral therapy and advance care planning have not been met. Specifically, the record does not include any clinical information to determine if Medicare coverage criteria have been met or if the billed services are distinct and separately identifiable. Therefore, we decided that the Plan does not have to pay for behavioral therapy for cardiovascular disease (G0446) and advance care planning (99497)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta.

You asked the Plan to pre-approve Zilretta. You say that you would like reconsideration because other drugs have not worked. The Plan denied your request. The Plan says you have already received this drug for each knee.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Zilretta. Our reviewer says that Zilretta is not intended for repeat administration. Our physician reviewer found based on the medical records provided and the Medicare-approved major drug compendia repeat administration of the requested drug is not safe and effective and otherwise reasonable and necessary for this enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Zilretta injections.

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 that the injections bring relief for knee pain.

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 Plan states that the services are not medically necessary; however, there are no medical records documenting your condition. Without medical records, a determination based on medical necessity cannot be supported. Therefore, we decided that the Plan has to pre-approve Zilretta injections.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a third level of paravertebral facet joint injections (64492).

You asked the Plan to pre-approve a third level of paravertebral facet joint injections. You say that this is medically necessary. The Plan denied your request. The Plan says a third level is not supported.

The Plan follows Medicare rules. Medicare rules say that for each covered spinal region (cervical/thoracic or lumbar), no more than two (2) thermal radiofrequency sessions will be reimbursed in any 12-month period, involving no more than four (4) joints per session, e.g., two (2) bilateral levels or four (4) unilateral levels.

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 third level of paravertebral facet joint injections. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the request exceeds utilization guidelines. only 2 levels can be performed in one session.

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 third level of paravertebral facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve a third level of paravertebral facet joint injections (64492).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Botox for the treatment of migraines.

You asked the Plan to pre-approve Botox. You say that you would like reconsideration because this service is
medically necessary. The Plan denied your request. The Plan says that there is no indication of the number of
migraine or other headaches occurring per month.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 Botox. Our reviewer says that the
requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found Botox (OnabotulinumtoxinA) is FDA-approved for the prophylaxis of headaches in adult
patients with chronic migraine (=15 days per month with headache lasting 4 hours a day or longer). The
documentation submitted supports that these criteria have been 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 Botox have been met. Therefore, we decided that the Plan has to pre-approve
Botox for the treatment of migraines.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services
with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and
effectively provide medically necessary and reasonable treatment in a SNF. Your functional level with 
non-weight bearing status does not require skilled therapy services with the specialized skill, knowledge and
judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable
treatment in a SNF. Skilled nursing or therapy services are not required on a "daily basis" or as a practical
matter on an inpatient basis, in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee was admitted and placed on a ventilator after suffering a large stroke. He has been taken off of the ventilator and is breathing on his own with supplemental 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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care.

You asked the Plan to pay for the acute inpatient hospital care. You say that it is felt that this was medically necessary inpatient care. The Plan denied your request. The Plan says that the enrollee could have been treated as an outpatient in observation.

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 the 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 enrollee is a female with a history of Parkinson's disease, quadriplegia, anemia and hypertension. She was admitted due to PEG tube dislodgement. She was scheduled for replacement, but this was rescheduled several times due to insurance issues and low potassium. Eventually, it was decided to forego PEG placement and the enrollee elected hospice. She was admitted to hospice. The record shows that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.

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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital 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.