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

We decided that the Plan does not have to pre-approve Eliquis tablets.
You asked the Plan to pre-approve Eliquis tablets. You say that this is necessary due to the enrollee's heart failure. 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 self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis tablets.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on May 14, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
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 has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider on May 14, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on September 22, 2019 through September 29, 2019.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because per CMS, CPT code S9328 is valid. The Plan denied your request. The Plan says CPT code S9328 has a status indicator of I and is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on September 22, 2019 through September 29, 2019.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs rehab to gain independent function. The Plan denied your request. The Plan says the enrollee does not need an intensive team to direct care.
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 that the enrollee's current level of function is ambulating with contact guard assist using a rolling walker, minimal assist with eating, moderate assist for upper body dressing, and maximum assist for lower body dressing. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's current medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional physical and occupational therapy, but her tolerance, functional level, and endurance do not indicate she requires this therapy on an intensive rehabilitation facility therapy program level 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the preparation of an oral appliance (21089).
You asked the Plan to pre-approve the dental item. You say that the enrollee previously had an occlusal guard. You say that it no longer fits and the enrollee needs a new one as her pain has since returned. You also say that you would like to treat the enrollee conservatively with an occlusal splint to decrease joint loading and help with the myofascial pain. The Plan denied your request. The Plan says occlusal splints are not a covered benefit under you medical plan.
Medicare generally does not cover dental services. The Plan follows the same rule. The service you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the preparation of an oral appliance (21089).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a combination sit-to-stand table system for the enrollee.
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 say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a combination sit-to-stand table system for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on November 1, 2019 through November 8, 2019.
You asked the Plan to pay for the home infusion therapy`. You say that you would like reconsideration because per CMS, CPT code S9328 is valid. The Plan denied your request. The Plan says CPT code S9328 has a status indicator of I and is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status indicator of I. This means that S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy` have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on November 1, 2019 through November 8, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on August 15, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you had a visit to make an appointment for the time and place of the preventive colonoscopy. You say you were told the preventive colonoscopy was free. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $45 copayment for each Medicare-covered specialist visit. You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the specialist office visit is considered a separate service.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the specialist office visit provided on August 15, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says that the Medicare criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the monitor. Our reviewer says that the requested monitor is medically reasonable and necessary. Our physician reviewer found the documentation does show that the CGM will be used in place of a blood glucose monitor for the enrollee for making diabetes treatment decisions (for example, changes in diet and insulin dosage). The enrollee checks blood sugar 4-10 times daily to reduce risk of symptomatic hypoglycemia. An appropriate evaluation for causes of symptomatic hypoglycemia has been performed. The CGM 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 monitor have been met. Therefore, we decided that the Plan has to pre-approve a continuous glucose monitor.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated wheelchair/scooter.
You asked the Plan to pre-approve the power operated wheelchair/scooter. You say that the records provided support the need for the requested power mobility device. The Plan denied your request. The Plan says the power operated wheelchair/scooter being requested is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the power operated wheelchair/scooter. Our reviewer says that the records do not show that the criteria for coverage have been met. Our physician reviewer found the documentation indicates the enrollee has a mobility deficit but there is no face to face evaluation or physician assessment with a detailed neuromuscular evaluation that indicates this personal mobility deficit impairs participation in mobility related activities of daily living or cannot be overcome sufficiently with a manual wheelchair or walker. There is no home evaluation indicating this enrollee can safely navigate a power mobility device in the home.
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 power operated wheelchair/scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power operated wheelchair/scooter.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for rabies vaccines (90675) provided from August 27, 2019 to September 9, 2019.
You asked the Plan to pay for rabies vaccines. You say that you needed these vaccines because you were bitten by an animal. The Plan denied your request. The Plan says that coverage of this vaccine is the responsibility of your Part D prescription drug plan.
Medicare covers vaccines if they are directly related to the treatment of an injury or direct exposure to a disease or condition. The Plan follows the same rules. The claims for these services show that you received the vaccines in question due to exposure to rabies. Rabies vaccines are directly related to the treatment of direct exposure to rabies. Therefore, we decided that the Plan has to pay for rabies vaccines (90675) provided from August 27, 2019 to September 9, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional eight fractions of intensity modulated radiation therapy (IMRT).
You asked the Plan to pre-approve the additional fractions. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical information provided did not support the medical necessity for the amount of treatment requested.
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 additional fractions. Our reviewer says that the requested additional fractions are not considered medically reasonable and necessary in this case. Our physician reviewer found the issue in this case is the number of fractions required for IMRT. The appeal letter tates that 2 Gy x18 is the standard of care, but offers no justification for this. Firstly, it is not clear that the new treatment field would overlap with the prior treatment field or that IMRT would be needed to prevent overlap. However, assuming that is the case (that IMRT can relatively spare the previously irradiated cauda equina) - treatment options that would be considered to be furnished in accordance with accepted standards of medical practice would be as follows: -SBRT (using IMRT) in 1-5 fractions. Abundant data (papers by Sahgal et al) support this. Also the ASTRO model policy for SBRT considers reirradiatoin to be an indication for SBRT -standard palliative regimens (using IMRT) in 5-10 fractions. The ASTRO model policy for IMRT considers reirradiatoin to be an indication for SBRT Therefore, it would be a standard of care to offer 10 fractions of IMRT. There is an absence of supporting rationale for the full request of 18 fractions. 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 additional fractions have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional eight fractions of intensity modulated radiation therapy (IMRT).
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve stereotactic body radiation therapy for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says that there must be documentation as to why IMRT or external beam radiation cannot be used.
The Plan must follow Medicare rules. Medicare rules say that services are covered when they are medically necessary and meet Medicare 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 the therapy. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is only offered SBRT to the liver metastases. She has no other sites of PET avid disease. Bone metastases are well-controlled, and apparently have not been active since diagnosed. Based upon published data, SBRT is the standard of care. While IMRT could be considered, its use would not be evidence-based. 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 therapy have been met. Therefore, we decided that the Plan has to pre-approve stereotactic body radiation therapy for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care.
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says this is not medically necessary.
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 the services. Our reviewer says that the requested inpatient mental health care is not medically reasonable and necessary. Our physician reviewer found that the records provided show that it was not expected this enrollee would improve in a reasonable period of time as she does not have suicidal or homicidal ideation noted and denies any auditory or visual hallucinations. The enrollee is not showing any acute threats to safety and was compliant with treatment. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she does not have dangerousness to self or others, but was compliant with her treatment. 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 inpatient mental health care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve semi-electric hospital bed (E0260).
You asked the Plan to pre-approve the semi-electric hospital bed. You say that the electric bed will help with feedings and receiving medications. The enrollee is mentally challenged and not able to move around on his own. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the semi-electric hospital bed.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 semi-electric hospital bed. Our reviewer says that the semi-electric hospital bed is not medically necessary for this enrollee. Our physician reviewer found the documentation does not support that the enrollee's condition requires positioning of the body in ways not feasible in an ordinary bed, frequent or immediate changes in body position or special attachments that cannot be fixed and used on an ordinary bed. 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 semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve semi-electric hospital bed (E0260).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Intensity-Modulated Radiation Therapy (IMRT) for the enrollee.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the cost in a clinical trial are covered by Original Medicare.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve the requested services as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Intensity-Modulated Radiation Therapy (IMRT) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve the injections. You say that you believe that this treatment should be approved. The Plan denied your request. The Plan says there is no evidence of failure of conservative treatment and there are possible sources of pain other than the facet joints which should be ruled out.
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered when the findings support a high likelihood that the facet joint is the source of the pain. 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 injections. Our reviewer says that the requested injections are not considered medically reasonable and necessary. Our physician reviewer found the patient has a positive straight leg raising test, multi-level degenerative disc disease and spinal stenosis, all of which can be probable sources of her back pain. Therefore, the criteria of the LCD are not met. The requested procedure is not medically reasonable or 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.