Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses provided on January 16, 2020.
You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. The Plan says the
member must use a doctor in the Plan's vision network.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan
covers these services with a doctor in the Plan's vision network.
We looked at the file and the Plan's rules. The file shows that the eyeglasses were provided by a provider that is
not in the Plan's vision network. Based on this information, we decided that the Plan's rules for coverage of the
eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for
eyeglasses provided on January 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiac genetic testing and pharmacogenetics panel.
You asked the Plan to pre-approve the testing. You say that this is needed for atherosclerotic heart disease. The
Plan denied your request. The Plan says no narrative description was provided to identify the testing
performed.
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 testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee has a past medical history of coronary artery disease. Submitted documentation is for one
telemedicine encounter in which no medications are recorded and no history of CAD evaluation or treatment
are recorded. A history of atherosclerosis is the only rationale given for ordering the tests in question. The
records do not support that this testing will directly impact medical treatment/management. It is not clear from
the records what tests are actually to be provided and therefore the record does not support whether the testing
is FDA approved.
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 testing have not been met. Therefore, we decided that the Plan does not have
to pre-approve cardiac genetic testing and pharmacogenetics panel.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient rehabilitation facility (IRF) services for the enrollee.
You asked the Plan to pre-approve IRF services. You say that IRF services are medically necessary. The Plan
denied your request. The Plan says that based on the medical records provided, Medicare criteria for IRF
admission are not met.
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 did not submit the medical record used to make their
decision. Without medical records, which the Plan states were present, we cannot substantiate the Plans denial.
Therefore, we decided that the Plan has to pre-approve inpatient rehabilitation facility (IRF) services 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture with a flexible base (CPT
D5226).
You asked the Plan to pre-approve the partial lower denture. You say that you recently got your teeth pulled.
You say that you cannot eat. The Plan denied your request. The Plan says Medicare does not covered this
service and it is not included in the supplemental dental coverage benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
mandibular partial denture with a flexible base (CPT D5226).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from December 14, 2019 through December 18, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the provided records did not show that inpatient care would be needed for at least two midnights following December 13, 2019. The inpatient services received from December 14, 2019 through December 18, 2019 were not supported as the enrollee appeared stable enough for discharge on December 14, 2019. Therefore, the inpatient services from these days will be considered 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 acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from December 14, 2019 through December 18, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Durvalumab.You asked the Plan to pre-approve Durvalumab. The Plan denied your request. The Plan says that the drug is not supported to treat neuroendocrine tumors of ovarian origin.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 Durvalumab. Our physician reviewer found that the request is for use of Durvalumab in combination with Carboplatin and Etoposide to treat small cell cancer from a liver metastasis presumed to be of ovarian origin. The results of an ordered CT lung were not submitted for review.The use of Durvalumab for ovarian cancers is not FDA approved.The use is not supported in any of the CMS approved compendia. This is a very rare type of cancer in the ovary. The NCCN Guidelines,Version 4.2020,Small Cell Lung Cancer lists the combination of Carboplatin, Etoposide and Durvalumab as one of the preferred primary treatment regimens for extensive stage small cell lung cancer.Given the rarity of this subtype of ovarian cancer, and the guidelines for treating this histologic cancer type in occult primary cancer, the requested use of Durvalumab is reasonable and 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 Durvalumab have been met.Therefore, we decided that the Plan has to pre-approve Durvalumab.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 admission to an inpatient rehabilitation facility (IRF).You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says three hours of therapy are not needed, and you do not need to see the doctor three times a week.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 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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that your functional status requires an 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 admission to an inpatient rehabilitation facility (IRF)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wheelchair component or accessory, not otherwise specified (K0108NU)provided on February 6, 2020 by an out-of-network provider.You asked the Plan to pay for the DME. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says the Plan will be paying the for cost of the wheelchair in full, however anything that is not medically necessary will not be covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The wheelchair cover is not a medically necessary item and is considered a convenience item. 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 pay for wheelchair component or accessory, not otherwise specified (K0108NU) provided on February 6, 2020 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the medical services. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are equally qualified in-network Radiation/Oncologists available to you that can provide the same treatment and treatment method you are requesting.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the retainer crowns.
You asked the Plan to pre-approve the retainer crowns. You say that you are suffering from a lot of pain and numbing. You say that this is medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
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 the retainer crowns when the services are medically necessary and reasonable. 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 retainer crowns. Our reviewer says that the criteria for coverage has not been met. Our physician reviewer found that there is no indication of any missing anterior or posterior teeth that have not been previously restored. Our physician reviewer also found that there are no currently missing teeth that require replacement and there is no documented physical or neurological disorder that would preclude placement of a removable prosthesis
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the retainer crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve the retainer crowns.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pain pump permanent trial for the enrollee.You asked the Plan to pre-approve the services. You say that this will help reduce opioid intake.The Plan denied your request. The Plan says the file states that there is a currently have an implanted programmable device.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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the NCD specifically precludes the simultaneous utilization of an intra-thecal pump and a spinal cord stimulator, which the enrollee has in place. Further, there is no peer reviewed literature supporting the simultaneous use of these two devices. The enrollee is also on high dose opiates even though he continues to have pain. 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 services have not been met.Therefore, we decided that the Plan does not have to pre-approve a pain pump permanent trial for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve E0601-continuous positive airway pressure (CPAP) device, E0561-humidifier, non-heated, used with positive airway pressure device, and A4604-tubing with integrated heating element for use with positive airway pressure device. You asked the Plan to pre-approve the CPAP device, humidifier and tubing. You say that you ask that the plan reconsider the decision to remove her CPAP and allow her to continue with therapy. The Plan denied your request. The Plan says this treatment is not medically necessary for the enrollee at this time. 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 CPAP device, humidifier and tubing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the coverage criteria for continued CPAP are not met. This enrollee has obstructive sleep apnea and has been prescribed CPAP but has not met the minimum usage criteria of at least 4 hrs./night for at least 70% of nights. Interface issues were addressed at the 1/30/2020 visit, but there has been no follow-up or compliance assessment since then. Because there is no evidence that the enrollee is meeting the minimum usage requirements, CPAP is considered 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 CPAP device, humidifier and tubing have not been met. Therefore, we decided that the Plan does not have to pre-approve E0601-continuous positive airway pressure (CPAP) device, E0561-humidifier, non-heated, used with positive airway pressure device, and A4604-tubing with integrated heating element for use with positive airway pressure device.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for BLS emergency ambulance service(A0429) and ground
mileage (A0425) provided June 14, 2019.
You asked the Plan to pay for the ambulance service. You say that this claim needs to be reconsidered. You
will find detailed information regarding why this claim should be reprocessed. The Plan denied your request.
The Plan says based on the records provided, it was not medically necessary for ambulance transport.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would
endanger the patient's health. The Plan follows the same rules.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the ambulance service. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee's presenting symptoms did not meet prudent layperson criteria for
emergency care. The documentation does not support that other means of transport were contraindicated. It
would have been safe for the enrollee to be transported by other means for further evaluation. The
documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining
equipment that only a fully-equipped ambulance can provide for safe transport. The enrollee had
stable vital signs and no abnormal findings on examination that required monitoring during transport. The
documentation does not support that the ambulance transport was medically reasonable and 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 the ambulance service have not been met. Therefore, we decided that the Plan
does not have to pay for BLS emergency ambulance service(A0429) and ground mileage (A0425) provided
June 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies for maintenance of non-insulin drug infusion catheter, per week (A4221) and infusion supplies for external drug infusion pump, per cassette or bag (A4222) provided to the enrollee from May 31, 2019 through June 7, 2019. You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Healthcare Common Procedure Coding System (HCPCS) code A4221 (1 Unit) remains not supported. The documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed code; therefore, the billed supply code cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. Healthcare Common Procedure Coding System (HCPCS) code A4222 (3 Units) remains not supported. The documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed code; therefore, the billed supply code cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. Therefore, we decided that the Plan does not have to pay for supplies for maintenance of non-insulin drug infusion catheter, per week (A4221) and infusion supplies for external drug infusion pump, per cassette or bag (A4222) provided to the enrollee from May 31, 2019 through June 7, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance transports provided to the enrollee on January 10, 2020 and January 14, 2020.You asked the Plan to waive the copayments for the ambulance transports. The Plan denied your request. The Plan says that cost sharing is a contractual obligation under the plan and cannot be waived.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with thePlan clearly says that enrollees must pay a $250 copayment for each one-way Medicare-covered ground trip. The enrollee has been asked to pay a $228.67 copayment for each of the ambulance transports. The ambulance transports fall within the one-way Medicare-covered ground trip benefit category. This means that the enrollee has been asked to pay less than 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 copayments for the ambulance transports provided to the enrollee on January 10, 2020 and January 14, 2020.