Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the application of a multi-layer compression system provided on March 12, 2021.

You asked the Plan to waive the copayment for the application of a multi-layer compression system. You say that you cannot afford 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 $350 copayment for outpatient surgery, including services provided at hospital outpatient facilities.

You received the application of a multi-layer compression system on March 12, 2021, at an outpatient hospital facility. The application of a multi-layer compression system is an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $145.99, which is less than the $350 copayment.

You have been asked to pay $145.99 for the application of a multi-layer compression system. The application of a multi-layer compression system 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 for the application of a multi-layer compression system provided on March 12, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve five fractions of stereotactic body radiation therapy (SBRT) for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that any course of radiation treatment extending beyond five fractions would not be considered stereotactic body radiation therapy and is not to be billed as such.
The Plan must follow Medicare rules. Medicare rules say that services are covered 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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has oligometastatic disease, and an argument could be made for SBRT. It could be considered an accepted standard of care. 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 five fractions of stereotactic body radiation therapy (SBRT) for the enrollee.
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) admission.

You asked the Plan to pre-approve SNF admission. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or therapy services on a daily basis or at an inpatient level in a SNF.

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 admission have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into a SNF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid provided on
December 7, 2020.

You asked the Plan to pay for the infectious agent detection. You say that you would like this claim to be
reprocessed for payment. The Plan denied your request. The Plan says Original Medicare would be responsible
for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

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 the infectious agent detection by nucleic acid provided on
December 7, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve the additional trips. You say that you do not have anyone to drive you to your appointments. The Plan denied your request. The Plan says this request is not covered.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a whole-body bone scan (78306), a computed tomography (CT) of the chest (71260), and a CT of the abdomen and pelvis (74177).

You asked the Plan to pre-approve a whole-body bone scan and CT scans of the chest, abdomen and pelvis. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

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 a whole-body bone scan and CT scans of the chest, abdomen and pelvis. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no clinical or biochemical evidence to imply recurrence.

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 whole body bone scan and CT scans of the chest, abdomen and pelvis have not been met. Therefore, we decided that the Plan does not have to pre-approve a whole-body bone scan (78306), a computed tomography (CT) of the chest (71260), and a CT of the abdomen and pelvis (74177).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital admission.

You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says that observation services are more appropriate.

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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record indicates that the enrollee was admitted after being found down unresponsive. The record indicates five falls within a month. The record indicates that the enrollee has a history of high blood pressure, congestive heart failure, peripheral arterial disease, and cognitive dysfunction. Physical examination demonstrated new onset aphasia as well as left sided weakness. Given the negative stroke work up, seizure and toxic encephalopathy were the differential diagnosis. The record documents the treating physician's reasonable expectation of a length of stay spanning 2 or more midnights. The elements of the coverage rule are satisfied. 

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 been met. Therefore, we decided that the Plan has to pay for inpatient hospital admission.

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 power seat elevation system.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. We looked at the file and Medicare rules. The requested item is a power seat elevation system. These services are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve testosterone gel.

You asked the Plan to pre-approve testosterone gel. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says testosterone gel is not covered under the enrollee's Medicare Part B benefit.

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 testosterone gel.

Benefits for testosterone gel 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adenomatous polyposis coli (APC) gene analysis
(81201, 81203).
You asked the Plan to pre-approve APC gene analysis. You say that you need this due to your family history.
The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted under codes
81201 and 81203 are unlikely to impact therapeutic decision-making in the clinical management of the patient
and will be denied automatically as not medically necessary.
We looked at the file and Medicare rules. The requested testing is unlikely to impact therapeutic decisionmaking
and is not considered medically necessary. Based on this information, we decided that Medicare rules
for coverage of APC gene analysis have not been met. Therefore, we decided that the Plan does not have to
pre-approve adenomatous polyposis coli (APC) gene analysis (81201, 81203).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
You asked the Plan to pre-approve the procedure. You say that the services are medically necessary. The Plan denied your request. The Plan says this procedure is experimental and is not covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested interspinous process devices remain experimental. More research is needed to show safety and efficacy of the devices. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
You asked the Plan to pre-approve the interspinous spacer placement. You say that the procedure is medically
necessary. The Plan denied your request. The Plan says this procedure is considered experimental and is noncovered.
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 interspinous spacer placement. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found the requested Vertiflex device is experimental. More research is needed to show
safety and efficacy of the device.
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 interspinous spacer placement have not been met. Therefore, we decided
that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a commode chair.

You asked the Plan to pre-approve these services. You say that you had a previous fall. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are confined to a bed or room. 

The file does not show that you are confined to a bed or room as defined by Medicare rules. Therefore, we decided that the Plan does not have to pre-approve a commode chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. The Plan denied your request. The Plan says this item
is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.

You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied
your request. The Plan says at this time, the criteria is not met for a new wheelchair.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the wheelchair. Our reviewer says that
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found you have a 1-
year-old power wheelchair that needs repair. You have canceled repairs previously. The documentation does
not support a significant functional decline or that the wheelchair is broken in a way that cannot be repaired.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the wheelchair have not been met. Therefore, we decided that the Plan does not
have to pre-approve a power wheelchair.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from
December 27, 2019, to February 19, 2020.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care
services to be 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 pay for home health services provided to the
enrollee from December 27, 2019, to February 19, 2020. Our reviewer says that Medicare coverage criteria are
not met. Our physician reviewer found in order to require Home health care skilled services, the member must
be confined to the home, under the care of a physician, and receiving services under a plan of care established
and periodically reviewed by a physician. Additionally, the enrollee must need skilled nursing care on an
intermittent basis or physical therapy or speech-language pathology; or have a continuing need for occupational
therapy. Being homebound means leaving home is a major effort. In this case, the documentation doesn't
support that the member required skilled rehab services to provide treatment that is medically necessary for the
dates in question or that there was an order for skilled therapy signed by a physician. The requested home
health services were not medically necessary. We looked at this physician's review, the file, and Medicare
rules. Based on this information, we decided that Medicare rules for coverage of these services have not been
met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee
from December 27, 2019, to February 19, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Arformeterol 15 mcg/2 ml.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy guidelines were not followed.
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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, you have not tried and failed the plan's required step therapy drug. There is no indication that the plan's required drug would likely be less effetive and/or likely have adverse effects for you. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Arformeterol 15 mcg/2 ml.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical nutrition therapy for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is a requirement for diabetes, kidney disease, or a kidney transplant
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pre-approve medical nutrition therapy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not take three shots insulin shots per day. The enrollee does not adjust insulin doses based on blood glucose levels. There is no reason given why glucometer testing would not suffice. 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee