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

We decided that the Plan does not have to pre-approve additional accessories for a power wheelchair (K0108, E2313, E2377) 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 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. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 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 not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the left upper extremity with the ability to feed himself indicates that the enrollee can control any power options through their own individual switches. The K0108 accessories - F3 Hub Cap Color Carbon Fiber and Color Kit Carbon Fiber do not serve a primary medical purpose and are 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional accessories for a power wheelchair (K0108, E2313, E2377) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom thigh-high compression stockings identified with code A6549 that were issued on October 27, 2020.

You asked the Plan to pay for the compression stockings. You say that you are not sure if the correct billing code was used in this case. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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. A6549 is the correct code to use in this case, and it is not coverable. Therefore, we decided that the Plan does not have to pay for the custom thigh-high compression stockings identified with code A6549 that were issued on October 27, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for computed tomographic (CT) colonoscopy 74263 provided August 21,2020.

You asked the Plan to pay for the CT colonoscopy. You say that you got a scan of your colon that was denied. Your doctor sent a letter. The Plan denied your request. The Plan says that the colorectal cancer screening can safely be done utilizing other means than CT colonoscopy.

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 pay for the CT colonoscopy. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of polyps in the past as well as a family history. The indicated colonoscopy was unsuccessful. The enrollee was unable to have a sufficient colonoscopy for colorectal screening because of technical reasons. There is literature support for the use of CT colonography in this setting. The requested service is 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 CT colonoscopy have been met. Therefore, we decided that the Plan has to pay for computed tomographic (CT) colonoscopy 74263 provided August 21,2020.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Armodafinil tablets.
You asked the Plan to pre-approve Armodafinil tablets. You say that the enrollee has had a good response to
this medication. The Plan denied your request. The Plan says coverage of this medication is the responsibility
of the enrollee's prescription drug plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Armodafinil tablets.
Benefits for Armodafinil tablets 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a practitioner visit provided on September 8, 2020 by an out of network (OON) provider.

You asked the Plan to pay for practitioner visit. You say that the facility obtained authorization. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a practitioner visit provided on September 8, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical epidural steroid injection.
You asked the Plan to pre-approve a cervical epidural steroid injection. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 a cervical epidural steroid injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic neck pain with radicular symptoms. The enrollee has had physical therapy, chiropractic services, transcutaneous electrical nerve stimulation (TENS), and medication trials. There is no documentation of the degree and duration of pain relief achieved by either previous injection received. There is no role for a series of three injections. Each injection must be evaluated for effectiveness, degree and duration of pain relief. Therefore, the enrollee does not meet criteria for the requested services. 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 cervical epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a cervical epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve office visits. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network provider.

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 office visits to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS HF system for the enrollee.

You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says this can only be approved when part of a clinical trial.

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 system. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has preserved ejection fraction and only mild symptoms of dyspnea. Cardiomems PA pressure monitoring has been shown to improve symptoms and decrease rehospitalization in patients with severe symptoms on full guideline directed therapy and with recent hospitalizations. However, the enrollee's recent hospitalization with decompensation was the direct result of an arrhythmic event --acute onset paroxysmal AF with rapid ventricular response and her symptoms improved rapidly with a return to sinus rhythm. She was seen for the first time in heart failure clinic recently, is not on a complex regimen and is on a very low dose of diuretics (Lasix 20mg) and beta blockers to treat her cardiac disease. There is no evidence she has not responded to standard outpatient management strategies, guideline directed medical management and regular clinical follow-up. In addition, she also has significant chronic lung disease likely contributing to her dyspnea symptoms. Given these specific clinical factors, she would not meet the published criteria or FDA indications for Cardiomems device implantation at this time and would therefore not meet the applicable CMS section 1862(a) medical reasonableness and necessity criteria.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the system have not been met. Therefore, we decided that the Plan does not have to pre-approve the CardioMEMS HF system for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the triamcinolone acetonide injection provided on April 24, 2020.

You asked the Plan to waive the coinsurance for the triamcinolone acetonide injection. You say that the injection helps you walk, and you shouldn't be charged for it. The Plan denied your request. The Plan says the coinsurance applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of the cost for Medicare Part B chemotherapy drugs and other Medicare Part B drugs. 

You have been asked to pay $119.26, which is 20% of the allowed amount for the triamcinolone acetonide injection. The triamcinolone acetonide injection falls within the "Medicare Part B prescription drugs" 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 triamcinolone acetonide injection provided on April 24, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram, complete, provided on November 25, 2020.

You asked the Plan to pay for the evaluation and management service. You say that the service should be covered. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the electrocardiogram, complete, provided on November 25, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility services beyond January 31, 2021.

You asked the Plan to pre-approve continued skilled nursing facility services. You say that the enrollee requires several months of SNF care. The Plan denied your request. The Plan says SNF services were not medically necessary after January 31, 2021.

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 continued skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee no longer qualified for SNF coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point were custodial and, as a practical matter, could be provided at a lower level of care (ex. intermittent therapy, restorative nursing therapy, LTC). 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility services beyond January 31, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twenty speech therapy visits for the enrollee.
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence that therapy will impact cognitive status.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested speech therapy therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had prior therapy, and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. The 20 requested sessions are excessive for the enrollee's condition. The enrollee has no aspiration or fluency difficulties. Her speech difficulties are increased with fatigue. Her deficits do not require 20 sessions of skilled speech therapy. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve twenty speech therapy visits for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral evaluation (D0120) and prophylaxis (D1110) provided on October 19, 2020.

You asked the Plan to pay for the dental services. You say that the wording for the in network and out of network services read the same. You say that when you received the bill you were confused that there was a balance due. You say that the document states there is a $0 copay for exams, cleanings, x-rays and fluoride. You also say that that is confusing and should be edited to reflect the coverage. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that out of network dentists may bill you for any amount greater than the MAC payment made by the plan to the 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 and the services are listed as covered, out of network dentists may bill you for any amount greater than the MAC payment made by the plan to the provider. Therefore, we decided that the Plan does not have to pay for the oral evaluation (D0120) and prophylaxis (D1110) provided on October 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
You asked the Plan to pre-approve the power seat elevation feature. You say that the seat elevation feature is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered as it is not primarily medical in nature. We looked at the file and Medicare rules. The requested item is non-covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power seat elevation feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic radiology services provided October 15, 2020.

You asked the Plan to pay for the diagnostic service. You say that this was a bone density scan which was preventative and covered under the plan. You do not believe this charge is correct. The Plan denied your request. The Plan says the claim processed and $125.17 was applied to the deductible.

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. 

The item or service you asked the Plan to pay 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. This is the amount you have to pay before the plan will pay their share for the covered medical services. This cost sharing is a contractual obligation that had not been met at the time the diagnostic service was received on October 15, 2020. Therefore, we decided that the Plan does not have to pay for the diagnostic radiology services provided October 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion device (22869).
You asked the Plan to pre-approve the Vertiflex device. You say that you highly recommend this minimally invasive procedure when conservative treatment has failed and as a safer alternative to a laminectomy or spinal fusion procedure. The Plan denied your request. The Plan says there is not enough studies on Vertiflex to show it is safe and effective to treat back pain. Vertiflex is investigational and experimental. The enrollee is not receiving this device as part of a Medicare covered clinical trial.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion device (22869).