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

We decided that the Plan does not have to pre-approve the POV, group 1 standard, patient weight capacity up to and including 300 pounds (CPT code K0800).
You asked the Plan to pre-approve the POV. You say that you have arthritis in both knees and they both have been replaced. You state if you stand for twenty (20) minutes your back hurts so bad that you cannot stand anymore. The Plan denied your request. The Plan says the Medicare rules have not been 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 pre-approve the POV. Our physician reviewer found a power operated vehicle (POV), group 1 standard, patient weight capacity up to and including 300 pounds (CPT code K0800) is not medically necessary per the Medicare LCD: Power Mobility Devices (L33789). You do not have a personal mobility deficit that impairs participation in MRADLs in the home. The documentation does not support that the enrollee's mobility deficit is unable to be helped by a cane, walker, or manual wheelchair. While you may have the cognitive ability to safely operate a POV in the home the documentation does not support that this requested K0800 device will significantly improve the enrollee's ability to participate in MRADLs in the home. 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 POV have not been met. Therefore, we decided that the Plan does not have to pre-approve the POV, group 1 standard, patient weight capacity up to and including 300 pounds (CPT code K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, diagnostic tests and injections provided by an out-of-network provider on April 10, 2020, July 2, 2020 and July 30, 2020.
You asked the Plan to pay for the office visit, diagnostic tests and injections. You say that authorization could not be obtained due to incorrect insurance information. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.
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 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 office visit, diagnostic tests and injections provided by an out-of-network provider on April 10, 2020, July 2, 2020 and July 30, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network mental health services provided to the enrollee on August 28, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The contract also states outpatient mental health care may require prior authorization. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 out of network mental health services provided to the enrollee on August 28, 2020.
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 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 the complexity of your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
syncope. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the back brace you received on June 25, 2020.
You asked the Plan to waive the coinsurance for the back brace. You say that the back brace is too big and doesn't fit properly. You say that you should not have to pay for something you cannot use. The Plan denied your request. The Plan says you were charged this coinsurance 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 durable medical equipment. You have been asked to pay 20% coinsurance for the back brace. The back brace falls within the durable medical equipment 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 back brace you received on June 25, 2020.
Your complaint about the fit of the back brace is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and additional intraoral periapical x-ray provided on December 15, 2020.
You asked the Plan to pay for the intraoral periapical x-rays. You say that you feel these services should be covered. The Plan denied your request. The Plan says these procedures are not a benefit under your dental 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. 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. The only x-rays covered under your plan are bitewing x-rays. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray and additional intraoral periapical x-ray provided on December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill
(S9986).
You asked the Plan to pre-approve the special supplemental benefits. You say that you were never told by the
plan that you would be ineligible for these benefits. The Plan denied your request. The Plan says you do not
meet the criteria to receive the benefits at issue.
The Plan must follow Medicare rules. Medicare rules say that medically necessary services are those that are
reasonable and necessary for the diagnosis or treatment of an illness or injury. These services are not covered
by Medicare. Since these services are not covered by Medicare, the plan's rules apply in this case.
We looked at the file and the plan's rules. The plan requires that the enrollee require intensive medical
management or be at high risk for hospitalization to receive these benefits. While the documentation signed by
the physician does show that the enrollee has one of the approved conditions, the documentation also shows
that the enrollee is not at high risk for hospitalization, nor do they require intensive management. Based on this
information, we decided that Medicare rules for coverage of the special supplemental benefits have not been
met. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the
chronically ill (S9986).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic foot with advanced features (L5987).
You asked the Plan to pre-approve the prosthetic foot with advanced features. You say that the prosthetic foot is medically necessary. The Plan denied your request. The Plan says the requested prosthesis is not correctly coded and cannot be approved as coded.
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 L5987 is not supported. Specifically, the requested Maverick Comfort AT foot has not been reviewed by the Pricing, Data Analysis, and Coding (PDAC) Contractor and subsequently published on the Product Classification List. Based on this information, we decided that Medicare rules for coverage of the prosthetic foot with advanced features have not been met. Please note that the plan has noted that a properly coded and approved prosthetic foot that meets the enrollee's needs can be approved if requested. Therefore, we decided that the Plan does not have to pre-approve a prosthetic foot with advanced features (L5987).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) care after March 29, 2021.
You asked the Plan to pre-approve SNF care. You say that the enrollee is not able to safely live on a long-term basis without skilled nursing. The Plan denied your request. The Plan says the denial of authorization for continued SNF care is correct.
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 the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) 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 continued Skilled Nursing Facility (SNF) care after March 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp (J0881).
You asked the Plan to pre-approve Aranesp. You say that you would like this drug to be approved for the enrollee. The Plan denied your request. The Plan says Aranesp is not reasonable or necessary for treatment of anemia due to sickle cell disease at this time.
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 Aranesp. Our reviewer says that Aranesp (J0881) is not medically reasonable and necessary for the enrollee. Our physician reviewer found Aranesp has been requested to treat anemia from sickle cell induced hemolysis. The Medicare compendia do not contain any positive citation for the requested drug for the noted indication as either an FDA-approved or as a non-FDA medically accepted indication. Our reviewer found that the coverage rule is not satisfied. Our physician reviewer also found that the requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp (J0881).
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 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 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 revision of a below the knee amputation to an above the knee amputation. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care for the enrollee to be provided at a non-participating plan provider.
You asked the Plan to pre-approve SNF care. 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 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 the enrollee required skilled rehab services to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of March 6, 2021, the enrollee did not require any skilled nursing or rehab services on a daily basis. The enrollee was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or ADLs. The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care as of March 6, 2021. The enrollee did not have any parental medications, complex wound care or nutrition given via a feeding tube. The enrollee received skilled care and improved, however their function had plateaued by March 6, 2021, and they did not require any further inpatient skilled rehab services.
The enrollee's function was at or near their prior level of function and they could be discharged to a lower level of care for further services. As of March 6, 2021, the enrollee required custodial services. The denial for further inpatient skilled care is upheld. 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 SNF care for the enrollee to be provided at a non-participating plan provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Perforomist (J7606).
You asked the Plan to pre-approve a tier exception for Perforomist. You say that Performist is indicated and medically necessary for the enrollee to be covered under her Medicare Part B benefits. The Plan denied your request. The Plan says Part B drugs are not eligible for tier cost reduction.
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 a tier exception for Perforomist have not been met. Specifically, the drug at issue is being covered by the Plan under Medicare Part B. Part B Drugs are not eligible for tier exceptions. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Perforomist (J7606).
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 enrollee appears to be needing more short-term acute care services for the time
being to help stabilize them which can safely be received at the current facility. The enrollee does not require
services at the LTACH that are not already available at the current facility. There are no services at the LTACH
that the enrollee requires that are not already available and covered at the current facility. Therefore, this
request for LTACH will be considered not medically necessary at this time. Transfer may be considered when
the enrollee is stable and when treatment has completed.
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 waive the copayments for the eye surgeries you had on March 27, 2020, and March 30, 3030.
You asked the Plan to waive the copayments for the two eye surgeries. You say that you were told you would only have a $400 copayment. The Plan denied your request. The Plan says you were charged these copayments correctly. You had two separate surgeries, so two separate surgery copayments apply.
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 $400 copayment for each surgery at an outpatient hospital facility. You have been asked to pay a $400 copayment for each of the two eye surgeries. The two eye surgeries fall within the surgery at an outpatient hospital facility benefit category. This means that you have been asked to pay the correct amounts 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 copayments for the eye surgeries you had on March 27, 2020, and March 30, 3030.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits provided from September 23, 2020, to October 7, 2020.
You asked the Plan to waive the copayments for specialist visits. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $35 copayment for specialist visits. You received specialist visits from September 23, 2020, to October 7, 2020, for a total of 3 visits. Therefore, you are responsible to pay a $35 copayment per each visit. The total amount you owe is: $35 (copayment) x 3 (specialist visits) = $105. You have been asked to pay the total copayment amount of $105 for specialist visits. Specialist visits fall within the physician/practitioner services, including doctor's office visits 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 copayments for specialist visits provided from September 23, 2020, to October 7, 2020.