Persius/hicric huggingface dataset:
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 you need a more intensive program to regain your mobility. The Plan denied your request. The Plan says your medical condition is not sufficiently medically complex.

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 there are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the radiological services (74230, 92611) provided January 5, 2021.

You asked the Plan to waive the co-payment for the radiological services. You say that you were assured this service would be covered. The Plan denied your request. The Plan says the co-payment has processed correctly in this case.

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). The enrollee's contract with the Plan clearly says that enrollees must pay a $110 co-payment for Basic Radiological Services.

The enrollee has been asked to pay a $110 co-payment for the radiological services. These services fall within the Basic Radiological Services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the co-payment for the radiological services (74230, 92611) provided January 5, 2021.

Your complaint about potentially receiving incorrect information regarding coverage is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on February 1, 2021.

You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says an eye refraction is not a covered benefit.

The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.

We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on February 1, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of lower joint/extremity.

You asked the Plan to pre-approve MRI of lower joint/extremity. You say that this service is medically necessary. The Plan denied your request. The Plan says that the requested MRI is not medically necessary and reasonable.

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 MRI of lower joint/extremity. Our reviewer says that the requested service is medically necessary and reasonable. Our physician reviewer found that you are a 43-year-old male with recent history of falls and left knee pain. Your plain radiographic images reveal medical and later tear of left knee meniscus. Your physician is ordering left knee MRI for further evaluation. Given the medical records reporting ongoing left knee pain in the setting of recurrent falls, it would be medically appropriate to further evaluate the left knee with an MRI in possible consideration of surgery or physical therapy options.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI of lower joint/extremity have been met. Therefore, we decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of lower joint/extremity.

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 admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that LTACH care is medically necessary. The Plan denied your request. The Plan says rules for LTACH 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 member has stabilized medically and has been receiving skilled services in a long-term acute care hospital (LTACH) with slow progress. The member continues to require skilled nursing and/or skilled therapy services on a daily basis. Although the member is making slow progress with therapy, there is no indication that transfer to a skilled nursing facility is required. They can continue to receive skilled services at the current level of care in an LTACH until discharge ready.

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 admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq.

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 medically necessary.

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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has hepatocellular cancer and is status post treatment with Lenvatanib. The Medicare approved compendia and literature support that Tecentriq and Avastin are approved only as first-line treatment; therefore, the Tecentriq is not safe and effective and reasonable and medically necessary for the enrollee 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Tecentriq.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say the enrollee had a femur fracture and is due to be discharged soon as the hospital is trying to get her home, but she needs acute rehabilitation in order to recover fully. You say the enrollee is very dependent and cannot live alone at home as there is no family available to assist. The Plan denied your request. The Plan says that the medical necessity criteria are not met for admission to acute inpatient rehabilitation.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture after a fall. Her medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a molecular pathology panel.

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 testing is not covered.

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 test at issue in this appeal, a molecular pathology panel, is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. The documentation shows that you state the testing outside of the approved BRCA genetic testing is not needed. Therefore, we decided that the Plan does not have to pre-approve a molecular pathology panel.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network oncologist.
You asked the Plan to pre-approve these services. You say that the enrollee needs to go to a provider close to a family member's home. The Plan denied your request. The Plan says the services are available from network providers.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network oncologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift.
You asked the Plan to pre-approve a stair lift. You say that you need a stair lift. 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 stair lifts are not covered because they
are not primarily medical in nature.
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.
Therefore, we decided that the Plan does not have to pre-approve a stair lift.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve elevating leg rests, expandable controller with harness, attendant control, and electronic connection for a power wheelchair (PWC).
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. Medicare rules say that power elevating leg rests are covered for specific indications only. The rules say that an attendant control (E2331) is provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered. The rules say that an expandable controller and harness with electronic connection is covered for multiple power options. We looked at the file and Medicare rules. The records show that you do not have a condition for which the power elevating leg rests are covered. The requested attendant control is not covered in addition to a beneficiary-operated joystick. The electronic connection and expandable controller with harness are not needed for a single-power option PWC. 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 pre-approve elevating leg rests, expandable controller with harness, attendant control, and electronic connection for a power wheelchair (PWC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
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 enrollee does not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific
criteria are met.
We looked at the file and Medicare rules. The records show that the enrollee is not insulin-treated with three or
more daily injections. 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 pre-approve a Freestyle Libre
continuous glucose monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation trips.
You asked the Plan to provide additional routine transportation trips. You say that you need transportation to your injection procedures, or you will get sick. The Plan denied your request. The Plan says you have exceeded your benefit limit.
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 provide additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SmartLux CCTV digital magnifier.
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 low vision aids are not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pre-approve are considered a low vision aid and are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a SmartLux CCTV digital magnifier.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
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 medically necessary.
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 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has hyperparathyroidism
and breast cancer. Prolia is indicated for those with breast cancer at risk of bone fracture; however, only while
on aromatase inhibitor. The records do not show that the enrollee is receiving an aromatase inhibitor as part of
her breast cancer treatment. The Prolia is therefore not safe and effective and reasonable and medically
necessary for the enrollee.
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 pre-approve Prolia.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the subsequent nursing facility care provided on October 9, 2020.
You asked the Plan to pay for the subsequent nursing facility care. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says that the services were rendered by a non-contracted provider and out-of-area. The Plan also says that there was no prior authorization.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and pre-approved care. 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 subsequent nursing facility care. Our reviewer says that the care provided was medically necessary for the enrollee's acute hip fracture, rehabilitation and physician monitoring and visits during her recovery. Our physician reviewer found the enrollee received oral medications. The enrollee had stable vital signs and her lungs were clear. The enrollee was weight bearing as tolerated and received skilled physical therapy and occupational therapy. Her medical problems were monitored and addressed. Her hip incision was covered with a dressing. Our reviewer found that the enrollee could not have foreseen requiring the services prior to leaving her service area. The records indicate that the care provided (or requested) was medically necessary. Our physician reviewer also found that it would not have been medically reasonable to delay the services until after January 31, 2021 when the enrollee disenrolled from the Plan. 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 subsequent nursing facility care have been met. Therefore, we decided that the Plan has to pay for the subsequent nursing facility care provided on October 9, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased September 15, 2020 from the out-of-network provider.
You asked the Plan to pay for the hearing aids. You say that you would like the Plan to provide $500 in reimbursement to you for the hearing aids. The Plan denied your request. The Plan says hearing aids purchased out-of-network are not covered by the Plan.
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 up to $500 for hearing aids only when purchased from an in-network provider. We looked at the file, and the Plan's rules. You purchased the hearing aids from an out-of-network provider. The Plan contract clearly states that hearing aids purchased out-of-network will not be covered by the Plan. Based on this information, we decided that the Plan's rules for coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased September 15, 2020 from the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided on December 16, 2019.
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that you would like this service to be covered. The Plan denied your request. The Plan says your intraoral x-rays benefit was exhausted.
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, intraoral x-rays are limited to one procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on December 16, 2019 which was covered by the Plan, and your intraoral x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided on December 16, 2019.