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

We decided that the Plan does not have to pre-approve CardioMEMS (33289, C2624).

You asked the Plan to pre-approve CardioMEMS. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is experimental and 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 CardioMEMS. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has mild congestive heart failure. The submitted record in its totality does not support that the enrollee has class III heart failure. The elements of the coverage criteria are not satisfied, and therefore, the requested service cannot be recommended at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CardioMEMS have not been met. Specifically, the enrollee does not meet the criteria The Food and Drug Administration has set for this service, and therefore, is not covered. Therefore, we decided that the Plan does not have to pre-approve CardioMEMS (33289, C2624).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator.

You asked the Plan to pre-approve a spinal cord stimulator. The Plan denied your request. The Plan says this is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that a spinal cord stimulator is covered for the indications established in the applicable LCD.

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 spinal cord stimulator. Our reviewer says that the requested spinal cord stimulator is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee already had a spinal cord stimulator device placed.

The results were not favorable. There are no records of a new trial stimulator. Criteria for a second implantable stimulator are not met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a spinal cord stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is necessary for the enrollee. The Plan denied your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee has no identifiable skilled nursing service needs. The enrollee does have identifiable skilled therapy service needs; however, the enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.

You asked the Plan to pre-approve the compression stockings. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this item does not meet the definition of a surgical dressing.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing.

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient surgery you had on November 29, 2020.

You asked the Plan to waive the coinsurance. The Plan denied your request. The Plan says you are responsible for the cost share.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 30% coinsurance for outpatient surgery.

Review of the file shows that you were provide outpatient surgery on November 29, 2020. You have been asked to pay a 30% coinsurance for the services, totaling $63.27. The services fall within the outpatient surgery 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 outpatient surgery you had on November 29, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 11, 2021.
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 had network providers available who could have provided 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 services provided by an out-of-network provider on January 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair accessories.
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the items are for convenience and not treatment of illness or injury.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.
The file shows that plastic sideguards, a seat pouch, quickie caddy, and mobility bag were requested. The items at issue do not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve the requested wheelchair accessories.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an ultrasound provided on December 28, 2020.

You asked the Plan to waive the deductible for an ultrasound. You say that the provider is showing as in-network on the website and this is an ongoing issue. 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. Your contract with the Plan says that there is a $250 deductible for out-of-network outpatient diagnostic tests and therapeutic services and supplies.

You received an ultrasound from an out-of-network provider on December 28, 2020. The record shows that you had paid $0 toward the $250 deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of $72.10.

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is a $250 deductible for out-of-network outpatient diagnostic tests and
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time
an ultrasound was received on December 28, 2020. Therefore, we decided that the Plan does not have to waive
the deductible for an ultrasound provided on December 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Keytruda (J9271) in combination with Gemcitabine (J9201) and Carboplatin (J9045) and antiemetic therapy Cinvanti (J0185) and Aloxi (J2469).

You asked the Plan to pre-approve Keytruda in combination with Gemcitabine and Carboplatin and antiemetic therapy Cinvanti and Aloxi. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested treatment is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Keytruda in combination with Gemcitabine and Carboplatin and antiemetic therapy Cinvanti and Aloxi.

Our reviewer says that the requested treatment regimen is not medically necessary. Our physician reviewer found that the requested treatment regimen is not FDA-approved for the enrollee's diagnosis or situation because the enrollee has had prior progression on immunotherapy and Carboplatin. The use of the requested treatment regimen is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda in combination with Gemcitabine and Carboplatin and antiemetic therapy Cinvanti and Aloxi have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Keytruda (J9271) in combination with Gemcitabine (J9201) and Carboplatin (J9045) and antiemetic therapy Cinvanti (J0185) and Aloxi (J2469).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits provided from September 8, 2020, to February 18, 2021.
You asked the Plan to waive the copayments for specialist visits. You say that you saw nurse practitioners not physicians and 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 $40 copayment for specialist visits.
You received specialist visits from September 8, 2020, to February 18, 2021, for a total of 5 visits. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $40 (copayment) x 5 (specialist visits) = $200. You have been asked to pay the total copayment amount of $200 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 8, 2020, to February 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung
cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. You say that the medical records provided will
show proof of medical necessity. The Plan denied your request. The Plan says the clinical information provided
does not support that the enrollee meets the criteria.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung
cancer screening for enrollees who meet all the above-described criteria.
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 low dose CT scan for lung cancer
screening. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found the enrollee is a 65-year-old female with nicotine
dependence. CT Thorax was requested for lung cancer screening. She is a former smoker with a total pack year
history of about 22.5. The current LCD Medicare coverage rules still require the 30-pack year history which
this patient does not meet. Therefore, the criteria for the requested LDCT have not been met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of low dose CT scan for lung cancer screening have not been met. Therefore, we
decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung
cancer screening.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.

You asked the Plan to pre-approve the requested bed. You say that you cannot get up and down from your bed. The Plan denied your request. The Plan says a total electric hospital bed is not covered by Medicare for any reason.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services, including a filling (D2391), endodontic
service (D3332), limited oral evaluation (D0140), analgesia and sedation (D9230, D9248), bone replacement
graft (D7953), surgical extraction (D7210), diagnostic consultation (D9310), surgical implants (D6010,
D6190), abutments and abutment supported crowns (D6057, D6058), cone beam image capture (D0383) and
diagnostic cast (D0470) provided from August 1, 2018, to December 1, 2020.

You asked the Plan to pay for the dental services. You say that these services are supposed to be covered under
your medical benefits. The Plan denied your request. The Plan says in general, dental services are not covered
by Original Medicare. The services in question are dental rather than medical and are not covered by Medicare
or by your Plan's benefits.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental services, including a
filling (D2391), endodontic service (D3332), limited oral evaluation (D0140), analgesia and sedation (D9230,
D9248), bone replacement graft (D7953), surgical extraction (D7210), diagnostic consultation (D9310),
surgical implants (D6010, D6190), abutments and abutment supported crowns (D6057, D6058), cone beam
image capture (D0383) and diagnostic cast (D0470) provided from August 1, 2018, to December 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee is able to participate in 3 hours of therapy per day but is unable to be safely discharged home at this point. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.

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 does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that the 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Favorable

The rules say that plans must pay for ambulance services when an emergency exists or when other means of transport would endanger the patient's health. An emergency is defined as when a prudent layperson would believe that without immediate medical attention there would be serious jeopardy to his or her health. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Managed Care Manual, Chapter 4, Sections 20.1 and 20.2.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.  Explanation of decisionWe decided that the Plan has to pay forthe ground mileage (A0425), and the emergency ambulance transport (A0429) provided on December 2, 2020.You asked the Plan to pay forthe transportation services. You say that the services were medically necessary.The Plan denied your request. The Plan says that the services do not meet the criteria for coverage.Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the transportation services. Our reviewer says that the transportation services are medically necessary. Our physician reviewer found the enrollee experienced similar symptoms in the past related to a stroke. Given this information, the reviewer found that the symptoms might have been another stroke. Therefore, the reviewer found that for a layperson (the enrollee and his daughter) this situation would appear like an emergency.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 transportation services have been met.Therefore, we decided that the Plan has to pay forthe ground mileage (A0425), and the emergency ambulance transport (A0429) provided on December 2, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided January 25, 2021.
You asked the Plan to pay for the fluoride varnish. You say that your dentist gave you incorrect information about coverage and you should not be responsible for the cost. The Plan denied your request. The Plan says this service is not covered under your benefits and the Plan provided the correct information about coverage to your provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided January 25, 2021.
Your complaint about potential misinformation provided by the contracted dental provider 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health services.

You asked the Plan to pre-approve inpatient mental health services. You say that the inpatient services are
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.

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 inpatient mental health services. Our
reviewer says that the inpatient mental health services are not medically necessary. Our physician reviewer
found the enrollee does not meet the criteria for treatment in an acute inpatient detoxification treatment and could be treated in a less restrictive setting. He is not showing any suicidal or homicidal ideation, auditory or visual hallucinations, and does not demonstrate any threats to safety. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health services.