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

We decided that the Plan does not have to pre-approve an anti-tipping device (E0971), battery charger (E2361) and adjustable angle footplate (K0040) for the enrollee.
You asked the Plan to pre-approve these items. You say that the member would not be able to propel an optimally configured manual wheelchair. The Plan denied your request. The Plan says that these items are included in the allowance for the base K0823 power wheelchair base and therefore are not separately payable.
The Plan must follow Medicare rules. Medicare rules say that codes E0971, E2361 and K0040 are included in the allowance for Group 2 Power Wheelchair base. Based on this information, we decided that Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not have to pre-approve an anti-tipping device (E0971), battery charger (E2361) and adjustable angle footplate (K0040) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve device to clean CPAP machine (A9270).
You asked the Plan to pre-approve device to clean CPAP machine. You say that you feel that this device should be covered because you cannot afford the hose, mask and filters to clean your CPAP machine. The Plan denied your request. The Plan says this device is used for cleaning equipment and not used to care for a medical problem and therefore, is not covered by Medicare for any reason.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve device to clean CPAP machine (A9270).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete eye exam (92015) provided on October 17, 2019.You asked the Plan to pay for the eye exam. You say that your doctor advised you to have an eye exam once every 6 months.The Plan denied your request. The Plan says the benefit maximum has been exceeded as the policy only covers one routine eye exam every year.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one routine eye examination every year.
We looked at the file and the Plan's rules. Based on this information, we decidedthat the Plan's rules for coverage of the eye exam have not been met. Specifically, the record indicates that you had a routine eye exam on January 17, 2019. The eye exam rendered on October 17, 2019 exceeds the benefit maximum. Therefore, we decided thatthe Plan does not have to pay for a complete eye exam (92015) provided on October 17, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998)
provided on September 18, 2019.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that as you were going
home the sand gave way and the car ended up in a hole. A Jeep came by and pulled your car out but one of the
helpers called 911 without your permission or knowledge. The Plan denied your request. The Plan says this
service is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on September 18, 2019. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport
(A0998) provided on September 18, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that this is medically necessary.The Plan denied your request. The Plan says your medical conditions have now stabilized, and you do not need daily physician oversight.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee is progressing in the SNF does not require this therapyon an intensive rehabilitation facility therapy program level 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a bi-level respiratory assist device without back-up rate (BiPAP).
You asked the Plan to pre-approve continued BiPAP use. You say that you use the machine every day and don't understand why it is not registering. The Plan denied your request. The Plan says that you do not meet minimum usage requirements to qualify for continuation of rental of your BiPAP equipment.
The Plan must follow Medicare rules. Medicare rules say that you must use the PAP 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. We looked at the file and Medicare rules. The compliance report included with the file indicates you did not adhere to therapy. Based on this information, we decided that Medicare rules for coverage of continued BiPAP use have not been met. Therefore, we decided that the Plan does not have to pre-approve continued use of a bi-level respiratory assist device without back-up rate (BiPAP).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided August 25, 2019 to August 28, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient level care was medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found blood testing and imaging were normal. The enrollee was restarted on Keppra, but no other acute care treatments were administered or planned. Based on the above clinical presentation and clinical course, there was no indication that this patient would have needed at least a two-midnight hospital stay. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided August 25, 2019 to August 28, 2019.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve weekly home health nursing visits beyond February 5, 2020.
You asked the Plan to pre-approve home health services. You say that ongoing care is needed. The Plan denied your request. The Plan says that there is no longer a need for home health services.
The Plan must follow Medicare rules. The rules say that a NOMNC must be issued prior to discontinuing coverage of home care services. The enrollee has been receiving home health services since September 9, 2019. There is no evidence that a NOMNC has been issued saying that coverage is ending for the home care services at issue in this appeal or providing a description of fast-track appeal rights. Therefore, we decided that the Plan has to pre-approve weekly home health nursing visits beyond February 5, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor system.
You asked the Plan to pre-approve a continuous glucose monitor and supplies. You say that your doctor told you about this device. The Plan denied your request. The Plan says the records show you are not on insulin or that you check your glucose levels four or more times a day.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. Criteria for a CGM have not been met. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor system.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient surgery provided on November 25, 2019.You asked the Plan to waive the copayment foroutpatient surgery. You say that you paid $350. You say that the Evidence of Coverage states a $200 copayment for both plans.The Plan denied your request. The Plan says the copayment 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 a $350 copayment for Medicare-covered ambulatory surgical center services.You have been asked to pay a $350 copayment for outpatient surgery. Outpatient surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 foroutpatient surgery provided on November 25, 2019
Appeal type: Step-Therapy
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 this is medically necessary.The Plan denied your request. The Plan says the enrollee has not tried Retacrit as required by step therapy rules.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 the criteria for coverage of Aranesp have not been met. Our physician reviewer found the documentation does not support that the enrollee has tried and failed Retacrit (Epoetin alfa-epbx), or that Retacrit would likely be less effective, or would likely have adverse effects for the enrollee in this case.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating provider without prior authorization.
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 has network providers available who can provide 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 medical services provided on October 4, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis for enrollee.You asked the Plan to pre-approve Restasis. You say that the enrollee has attempted use of multiple artificial tears without improvement.The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.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 Restasis for enrollee.Benefits for Restasis 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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the insertion of a chest wall heart monitoring device (33285).
You asked the Plan to pre-approve the insertion of a chest wall heart monitoring device. You say that this is medically necessary. The Plan denied your request. The Plan says that there are not medical records from the specialist to show this procedure is necessary.
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 the insertion of a chest wall heart monitoring device. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has complex cardiovascular disease and rapid paroxysmal atrial flutter. He could be maintained on lifelong anti-coagulation and anti-platelet agents which would put him at increased risk for bleeding over the longer term. He was also offered the opportunity for atrial flutter ablation followed by surveillance with an implantable loop recorder to assess for recurrence of asymptomatic atrial flutter or fibrillation. If he did not have further flutter or fibrillation over a prolonged period of monitoring, he would not require long-term anti-coagulation. If he had symptomatic or asymptomatic recurrence, he would require either repeat ablation or initiation of anti-coagulation to lower his risk of embolic stroke. Although atrial flutter ablations are often successful over the long-term, asymptomatic recurrence is a possibility and continuous and more prolonged monitoring post procedure is necessary to rule out recurrence of the dysrhythmia. This is best done with and implantable loop recorder which is the most efficient technology at assessing recurrence of atrial flutter or fibrillation post ablation. Therefore, the implantable loop recorder is both reasonable and medically necessary for the treatment of this patient's clinical condition and meets the coverage criteria. 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 insertion of a chest wall heart monitoring device have been met. Therefore, we decided that the Plan has to pre-approve the insertion of a chest wall heart monitoring device (33285).
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service coded 81479 provided on March 29, 2019.
You asked the Plan to pay for the laboratory service. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory service coded 81479 provided on March 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forspecialist clinic services received from July 5, 2018 to July 27, 2018.You asked the Planto pay forthe services. You say that the services were not filed to your insurance.The Plandenied your request. The Plansaysthe claim was not filed timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the services was not filed until August 12, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plandoes not haveto pay forspecialist clinic services received from July 5, 2018 to July 27, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve a shower chair.You asked the Planto pre-approve a shower chair. You say that the enrollee requires a shower chair for his health.The Plandenied your request. The Plansaysthis is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plandoes not haveto pre-approvea shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous glucose monitor supplies provided on July 19, 2019.

You asked the Plan to pay for continuous glucose monitor supplies (K0553). You say that the supplies were medically necessary. The Plan denied your request. The Plan says there is no physician order or delivery receipt for the supplies.

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 shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a current physician order or proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for continuous glucose monitor supplies provided on July 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE).
You asked the Plan to pre-approve the TTE. You say that it is felt that the TTE is medically needed. The Plan
denied your request. The Plan says this testing is not medically necessary at this time.
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 TTE. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found based on the records, the patient has known coronary disease but no recent cardiac symptoms, a normal
cardiovascular physical exam and a prior normal echocardiogram. In this setting, the documentation does not
support the medical necessity for a repeat echocardiogram since there are no new cardiac symptoms and no
new murmurs or other abnormalities on physical exam.
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 TTE have not been met. Therefore, we decided that the Plan does not have
to pre-approve a transthoracic echocardiogram (TTE).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve supply allowance for therapeutic continuous glucose monitor.
You asked the Plan to pre-approve supply allowance for therapeutic continuous glucose monitor. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested supply is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that supplies for therapeutic CGMs are only covered when the therapeutic CGM is covered. Review of the file shows that you do not meet criteria for the CGM. You are not using 3 or more insulin shots daily. You are not experiencing hypoglycemic episodes. The documentation supports that you are under good control and do not require frequent adjustments. Therefore, you do not meet criteria for the requested CGM supplies. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of supply allowance for therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve supply allowance for therapeutic continuous glucose monitor.