Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on October 21, 2017.
You asked the Plan to pay for the hearing aids. You say that the supplier of the hearing aids never filed because
they were paid in full and you are requesting reconsideration as you just discovered the hearing aids were
reimbursable. The Plan denied your request. The Plan says this request was received past the timely filing limit.
The plan also confirmed that per page 96 of the 2017 Evidence of Coverage routine hearing exams, hearing
aids or exams to fit hearing aids was not covered by the plan.
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 hearing aids was not filed until June 17, 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
Plan does not have to pay for the hearing aids purchased on October 21, 2017.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on May 16, 2019.
You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says train of four monitoring is considered a bundled procedure and payment for it is included in payment for the already approved neuromonitoring.
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 95999 is not supported in the record. Specifically, train of four monitoring is considered integral to the primary procedure and therefore is part of a bundled payment. Based on this information, we decided that Medicare rules for coverage of the train of four monitoring have not been met. Therefore, we decided that the Plan does not have to pay for train of four monitoring (95999) provided on May 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay for the presumptive and definitive drug testing provided on April 19, 2019.You asked the Planto pay forthe drug testing. You say that the documentation submitted supports the billing of these services.The Plandenied your request. The Plansaysthe custom profile forms are not dated within the time frame to make them valid for the date of service at issue.The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by a treating provider.In this case, the filedoes not include any lab order. The only document submitted is a form which describes what is included in the ordering provider's custom panel. There is no evidence of this panel being ordered by the provider for the date at issue and the profile form describing the custom panel is dated after the date of service.Therefore, we decided that the Plandoes not haveto pay forthe presumptive and definitive drug testing provided on April 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652)
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 the services are necessary. The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.
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 is currently undergoing treatment at an acute care hospital (ACH) for pneumonia following recent thoracic surgery. The enrollee is not intubated/ventilated. 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 long term care (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 long term acute care hospital (LTACH) services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services (SNF) provided to the enrollee on May 20, 2019 to May 31, 2019.
You asked the Plan to pay for skilled nursing services. You say that the Plan should consider the appeal for coverage. The Plan denied your request. The Plan says the member elected hospice on May 20, 2019. While on hospice, skilled nursing facility level services are not a covered benefit.
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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for skilled nursing services (SNF) provided to the enrollee on May 20, 2019 to May 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the arm joint.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show the results of an x-ray taken after the symptoms started.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found there is no positive Hawkins or impingement finding. No significant weakness with 4/5 resisted abduction noted. This enrollee apparently has been evaluated for left shoulder pain in the past and prior imaging reports and PT records are not submitted for review. While plain x-rays would not reveal rotator cuff tear, they would be useful for calcific peritendinitis and degenerative joint disease. Based upon the material submitted medical necessity for MRI of the left shoulder is not yet established. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the arm joint.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveImfinzi.You asked the Plan to pre-approveImfinzi. You say that this is unrelated to the clinical trial.The Plan denied your request. The Plan says that this drug is part of a clinical trial.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We found that the requested drug is not the drug being studied in the clinical trial at issue. 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 Imfinzi. Our reviewer says that the requested drug is medically necessary. Our physician reviewer found Imfinzi (durvalumab) is FDA approved for the treatment of unresectable stage III non-small cell lung cancer which has not progressed following concurrent platinum-based chemotherapy and radiation therapy. This patient meets this 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 Imfinzi have been met.Therefore, we decided that the Plan has to pre-approveImfinzi.
Appeal type: Imaging
Decision: Favorable

We decided that the Planhasto pre-approve MRI of the brain for the enrollee.You asked the Planto pre-approvethe MRI. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthe notes do not show any of the covered indications for the imaging.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found the enrollee diabetes, and the visual disturbance is probably related to this. However, the prior insect bite and soft tissue swelling commensurate with the blurred vision development are somewhat disturbing and prior to further treatment it is reasonable to perform MRI of the orbits and brain to exclude a structural abnormality as the cause of her blurred vision.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 MRI have been met.Therefore, we decided that the Planhas to pre-approveMRI of the brain for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approveCT scan of the brain for the enrollee.You asked the Plan to pre-approvethe scan. You say that this is medically necessary.The Plan denied your request. The Plan says that the criteria requires abnormal labs orother test results.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found has a history of headaches anda palpable scalp abnormality. Conventional x-rays would likely be non-contributory and even if negative would not exclude a calvarial lesion. In order to full analyze the inner and outer tables of the skull as well as the underlying brain CT of the brain/skull would be the best procedure of choice and should be approved.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 scan have been met.Therefore, we decided that the Plan has to pre-approveCT scan of the brain for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for hearing aids.You asked the Plan to pre-approve these services. You say that the enrollee needs new hearing aids.The Plan denied your request. The Plan says the services are covered from a network provider only.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only from a network provider.We looked at the file and the Plan's rules. The services are not being requested from a network provider. Based on this information, we decided thatthe Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approvea referral for hearing aids.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 6, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on November 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Apixaban provided on October 7, 2019.You asked the Plan to pay forthis drug. The Plan denied your request. The Plan says that self-administered drugs are not covered under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay forthe Apixaban provided on October 7, 2019.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.You asked the Plan to pre-approve the compression stockings. You say that the claim should be paid.The Plan denied your request. The Plan says gradient compression stockings A6530 are non-covered when there is no qualifying wound.The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6530 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6530
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forthe subsequent hospital care provided on September 26, 2019.You asked the Plan to pay forthe hospital care. You say that two physicians of different specialties provided services on the date of service.The Plan denied your request. The Plan says that the charge for this service is included in another procedure code.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 looked at the file and the rules. The medical records show the services at issue were provided, a pulmonologist. The discharge services were provided an internal medicine physician. The services were provided by two different physicians of different specialties. Based on this information, we decided that Medicare rules for coverage have been met. Therefore, we decided that the Plan has to pay forthe subsequent hospital care provided on September 26, 2019.
Appeal type: Other
Decision: Favorable

We decided that the Plan has to pre-approve critical intervention services.
You asked the Plan to pre-approve the services. You say that the plan does not provide programs that are specialized to assist people who are developmentally disabled with low communication skills. The Plan denied your request. The Plan says that these services are not primarily medical in nature, and therefore are not covered.
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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found you have outbursts at your group home, and pain as well. You could benefit from therapeutic services. This review indicates that the requested services are medically reasonable and 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 services have been met. Therefore, we decided that the Plan has to pre-approve critical intervention services.
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. The Plan denied your request. The Plan says the enrollee does not need daily physician care, and cannot tolerate intense therapy.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 physician reviewer found that the enrollee's medical conditions appear stable. There is no complex wound care needs. There are no unaddressed medical issues. She does not require medical oversight of her condition at an acute hospital level of care. The enrollee requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. However, she has limited short-term goals of being able to perform bed mobility and transfers to a wheelchair without hands on assistance. She is limited by debility and the severity of her comorbid medical conditions. The enrollee would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on October 14, 2019.You asked the Plan to pay forlab services. You say that the Plan should supplement Medicare payment.The Plan denied your request. The Plan says during the election, fee-for-service Medicare covers attending physician services and all care unrelated to the terminal illness starting on the date of the Hospice election until the first day of the month following the month in which Hospice is revoked or discharged.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 dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe lab services provided to the enrollee on October 14, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires or that the enrollee has truncal swelling in addition to the swelling of the extremities.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).