Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Nucala 100 mg subcutaneous sol (J8282).
You asked the Plan to pre-approve Nucala. You say that this service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that the service is not medically necessary for the enrollee.
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 Nucala. Our reviewer says that the requested service is medically necessary. Our physician reviewer found this patient's medical condition responds to corticosteroids, but they have developed a complication of osteoporosis as a result of this therapy. Therefore, an alternative to steroid treatment is needed with case reports indicating Nucala as an effective alternative. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Nucala have been met. Therefore, we decided that the Plan has to pre-approve Nucala 100 mg subcutaneous sol (J8282).
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the documentation does not support that you require services at the LTACH that are
not available at the acute care hospital where you are currently receiving care. There are no required medical
services identified that are available at the LTACH, that are not available at the current health care setting
being offered by the health plan. Consequently, the requested LTACH services are not medically necessary,
reasonable, and appropriate for your diagnosis and condition 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120) and
prophylaxis - adult (D1110) provided on May 5, 2020.
You asked the Plan to pay for a periodic oral evaluation and prophylaxis. You say that the service should be
covered. The Plan denied your request. The Plan says you are responsible for all fees in excess of the allowed
amount for services received from an out-of-network 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. You may be billed more by an
out-of-network provider if the charge is greater than MAC; you are responsible for the difference between the
amount billed and the amount allowed.
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. Specifically, you are responsible for the difference between the MAC
allowable and the cost of the out-of-network provider charges. Therefore, we decided that the Plan does not
have to pay for a periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110)
provided on May 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and base
upgrade (K0108).
You asked the Plan to pre-approve a power seat elevation system and base upgrade. You say that you need
these items for safe transfers. The Plan denied your request. The Plan says these items are not covered.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature and power
standing feature are non-covered because they are not primarily medical in nature.
We looked at the file and Medicare rules. The requested power seat elevation feature is not covered by
Medicare. The record indicates that the base upgrade is also an increased elevation feature. Based on this
information, we decided that Medicare rules for coverage of a power seat elevation system and base upgrade
have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation
system (E2300) and base upgrade (K0108).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not require an intensive, complex, multidisciplinary approach to daily therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found you were admitted to the acute hospital for surgical repair of a hip fracture after a fall. You have been discharged to a skilled nursing facility. Your medical conditions are stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 above 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 based on the medical records provided daily skilled services are not required. You do not require the services on an inpatient basis, in a skilled nursing facility setting. Services in the home or in an assisted living facility with home health services or in a long-term care facility on a part time basis appear appropriate in this case. 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 skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out-ofnetwork
(OON) provider.
You asked the Plan to pre-approve physical therapy. You say that your home physical therapist referred you to
this provider because no one else can treat you. The Plan denied your request. The Plan says the denial of
authorization for these services is correct, because this provider is out-of-network with the Plan and you can be
treated by an in-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
the medical services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve OON services. You say that the requested provider has more experience.
The Plan denied your request. The Plan says there are in-network general surgeons who are available.
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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve
medical services to be provided by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a stress test and does not have to waive the coinsurance for medical supplies and a Medicare Part B drug provided on August 12, 2020.
You asked the Plan to waive the copayment for a stress test and to waive the coinsurance for medical supplies and a Medicare Part B drug. You say that you disagree with the charges beyond the $110 copayment. 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 $25 copayment for non-radiological diagnostic services. Your contract with the Plan also clearly says that you must pay 20% coinsurance for medical supplies and Medicare Part B prescription drugs. You received a stress tests on August 12, 2020. Therefore, you are responsible to pay the $25 copayment. You received medical supplies on August 12, 2020. The allowed amount is $240.96 and 20% of that is $48.19. You received a Medicare Part B drug on August 12, 2020. The allowed amount is $7.04 and 20% of that is $1.41. You received a Medicare Part B drug on August 12, 2020. The allowed amount is $235.12 and 20% of that is $47.02.
The total allowed amount you owe is: $121.62. You have been asked to pay the total amount of $121.62 for a stress test, medical supplies and a Medicare Part B drug. A stress test and medical supplies fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. A Medicare Part B drug 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 copayment for a stress test and does not have to waive the coinsurance for medical supplies and a Medicare Part B drug provided on August 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 pressure-reducing support surface.
You asked the Plan to pre-approve the Group 2 support surface. You say that the enrollee has a history of
ulcers, and you feel that she may be developing a new one. You believe that the plan should cover this surface
in order to prevent an ulcer and not have to wait until one develops. The Plan denied your request. The Plan
says the enrollee does not currently have any stage II or higher pressure ulcers for which the use of this type of
surface can be covered.
The Plan must follow Medicare rules. Medicare rules say that Group 2 pressure-reducing surfaces are covered
for the treatment of active stage II or higher pressure ulcers.
In this case, there is no evidence of stage II or higher wounds. There has been no documented trial of a Group 1
support surface. Although the requested item may be appropriate for prevention of ulcers, Medicare coverage
does not extend to this indication. Therefore, we decided that the Plan does not have to pre-approve a Group 2
pressure-reducing support surface.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lift chair (E1399).
You asked the Plan to pre-approve the chair. You say that the lift chair is medically necessary. The Plan denied
your request. The Plan says only the lift mechanism is covered. The chair itself is not primarily medical in
nature and is not covered.
The Plan must follow Medicare rules. Medicare rules say that only the lift mechanism is a covered benefit. The
chair itself is non-covered.
We looked at the file and Medicare rules. The chair was billed using code E1399. The chair must be billed
using CPT code A9270 as it is a non-covered item. Based on this information, we decided that Medicare rules
for coverage of the chair have not been met. Therefore, we decided that the Plan does not have to pre-approve a
lift chair (E1399).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Autologous Bone Marrow Mesenchymal Stem Cell Injections to Left Knee.
You asked the Plan to pre-approve these services. You say that this would help you with your pain. The Plan denied your request. The Plan says that this service is considered experimental.
The Plan must follow Medicare rules. Medicare rules say that autologous HPC transplantation is covered for the above listed indications. We looked at the file and Medicare rules. The record shows that this is being requested for osteoarthritis, which is not listed as a covered indication. 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 Autologous Bone Marrow Mesenchymal Stem Cell Injections to Left Knee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI) (78452).
You asked the Plan to pre-approve MPI. You say that the services are necessary. The Plan denied your request.
The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that MPI is covered when specific criteria is met.
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 MPI. Our reviewer says that the
services are not medically necessary. Our physician reviewer found based on the records the enrollee has some
coronary risk but no anginal symptoms, no documented LV dysfunction and no ischemic electrocardiographic
changes. Likewise, there is an alternative likely explanation for exertional dyspnea, that being hypertensive
heart disease and atrial fibrillation. Atrial fibrillation alone is not considered and appropriate indication for
nuclear stress testing according to established guidelines (see reference). Overall the documentation does not
support the medical necessity for nuclear stress testing and coverage criteria at 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 MPI have not been met. Therefore, we decided that the Plan does not have to
pre-approve myocardial perfusion imaging (MPI) (78452).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
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 item is not covered.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate
and needed for use inside the home.
The item at issue in this appeal is for use outside of the home. The file shows that you will not be keeping the
power scooter in your home. Although this item may be helpful, neither Medicare nor the Plan covers
equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power
scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower partial denture for the enrollee.
You asked the Plan to pre-approve the denture. You say that this is medically necessary. The Plan denied your request. The Plan says there is no coverage for this request.
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. Dentures are not listed as a covered benefit in the Evidence of Coverage. Based on this information, we decided that the Plan's rules for coverage of the denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a lower partial denture for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the lumbar spine.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says that the provider is not approved for the requested services at this location.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan has not substantiated their denial in this case. The plan has not explained why exactly the requested provider is not approved at the requested location. The denial reason is vague and incomplete. The plan has not provided any medical records for our review. It does not appear that they ever requested any medical records. Therefore, we decided that the Plan has to pre-approve MRI of the lumbar spine.
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 pre-approve a mandibular partial denture.
You asked the Plan to pre-approve a mandibular partial denture. You say that this is medically necessary for
you to eat and allow you to swallow food. The Plan denied your request. The Plan says that until after 5 years a
new prosthesis is not paid for the same area.
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. The Plan covers a mandibular
partial denture once every five years.
We looked at the file and Medicare rules. The file indicates you received a mandibular partial denture on June
27, 2019, which is less than five years ago. Based on this information, we decided that the Plan's rules for
coverage of a mandibular partial denture have not been met. Therefore, we decided that the Plan does not have
to pre-approve a mandibular partial denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement denture.
You asked the Plan to pre-approve the services. You say that you accidentally lost your previous lower partial. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.
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. The Plan covers dentures once every five years. Dentures were previously received less than five years ago on April 4, 2019. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove the power recline features for the power wheelchair
(E2311, E2377, E2313).
You asked the Plan to preapprove power recline features.. You say that the enrollee requires these features. The
Plan denied your request. The Plan says the requested codes (E2311, E2377, E2313) exceed the member's
needs and cannot be covered.
The Plan must follow Medicare rules. The notes state that these are needed when 3 or more actuators are being
used. The electrical connection between the wheelchair controller and two or more motors (E2311), expandable
controller(E2377) and harness (E2313) cannot be covered. Although there are three approved power options on
this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options through the joystick. Member's upper limb strength and function are adequate for the member to be able to
control the power options using their own switches which are included in the allowance of these power options.
Therefore, we decided that the Plan does not have to preapprove the power recline features for the power
wheelchair (E2311, E2377, E2313).