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

We decided that the Plan does not have to pre-approve power wheelchair accessories (a power seat lift, anterior kilt kit, harness, expandable controller, electronic connection, and LED light kit).
You asked the Plan to pre-approve the accessories. You say that these accessories are medically necessary. The Plan denied your request. The Plan says this is 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 the accessories. Our reviewer says that the requested accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found the rules say that the power seat elevation feature (E2300) is not medically necessary as it is not primarily medical in nature. The anterior tilt kit (K0108) - a modified power standing feature that allows this patient to partially stand as the chair is tilted anteriorly and forward is not medically necessary as it is not primarily medical in nature. Per Medicare guidelines if a wheelchair has an electrical connection device described by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power standing feature, it will be denied as non-covered. The documentation does not reveal that you require a proportional input device, an attendant control, other electronic devices such as augmentative speech device, a separate display, a non-proportional input device such as sip and puff, or the need to control 3 or more power seating actuators through the drive control. Your strength is sufficient to control any power options with their separate switches therefore the request for a harness, controller, electrical connection is not medically necessary. The LED light kit is a convenience item and therefore 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve power wheelchair accessories (a power seat lift, anterior kilt kit, harness, expandable controller, electronic connection, and LED light kit).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on September 27, 2019.
You asked the Plan to pay for the knee orthoses (L1851) and suspension sleeves (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says rules for telehealth services were not met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on September 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not covered.
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 Keytruda 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 Keytruda.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 21, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the provider is a hospitalist physician with the group and depends upon hospital staff to verify eligibility and to obtain the proper authorization. The Plan denied your request. The Plan says non-emergent services rendered by non-participating provider is non-participating facilities require prior authorization.
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 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 the medical services provided on August 21, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve correction of bunion on the left big toe for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says that no new clinical information was provided to support the medical necessity of this procedure.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the requested surgery is considered medically reasonable and necessary in this case. Our physician reviewer found Medicare advises that they will authorize and pay for treatment of a painful malformed body member. In this particular case it is well documented that this enrollee suffers with a lateral deviated hallux with increased intermetatarsal angle and hallux valgus angle. The enrollee states that she has failed conservative treatments for her painful bunion. Medicare guidelines advised that they will reimburse for treatments that are safe and effective, not mainly for the convenience of the physician or the patient, not experimental, and appropriate for the patient's condition. The left bunion surgery for this enrollee meets all of the above mentioned 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 surgery have been met. Therefore, we decided that the Plan has to pre-approve correction of bunion on the left big toe for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on June 4, 2019.
You asked the Plan to waive the copayment for the office visit. You say that the office visit was unnecessary. You say that you never should have been charged. The Plan denied your request. The Plan says the copayment 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $50 copayment for Medicare-covered vision services. The enrollee has been asked to pay a $50 copayment for the office visit. The office visit falls within the "Vision care" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit provided on June 4, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services (99308) provided on July 3, 2019.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were provided out-of-network and there was no preauthorization provided. The services were not emergent.
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 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 the physician services (99308) provided on July 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit 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 step therapy requirement is not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of unspecified anemia and severe stage four chronic kidney disease. The records do not show that he has tried and failed the plan's required drug of Retacrit or that it would be less effective or contraindicated. Retacrit is therefore not reasonable or medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee on January 30, 2019 to April 8, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee on January 30, 2019 to April 8, 2019.
Benefits for these services 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on September 30, 2019.
You asked the Plan to pay for the shoulder-elbow-wrist-hand orthosis (L3960). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says rules for telehealth services were not met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on September 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex interspinous and/or interlaminar device (22869).
You asked the Plan to pre-approve a Vertiflex interspinous and/or interlaminar device. You say that the service is medically necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
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 Vertiflex interspinous and/or interlaminar device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer remains experimental. More research is needed. 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 Vertiflex interspinous and/or interlaminar device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex interspinous and/or interlaminar device (22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from September 5, 2019 to September 13, 2019.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that your bill is due to being put in a private room. You say you had no control over what room you were in. 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 $360 copayment per day, days 1 to 5 for an in-network inpatient hospital and a $0 copayment per day, days 6 to 90 for an in-network inpatient hospital. You have been asked to pay a $1,530 copayment, which is less than the standard copayment, for the inpatient hospital stay. The inpatient hospital stay falls within the "Inpatient hospital care" 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 the inpatient hospital stay provided from September 5, 2019 to September 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of wireless pressure sensor into lung artery via catheter (CardioMEMS device).
You asked the Plan to pre-approve insertion of wireless pressure sensor into lung artery via catheter. 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 insertion of wireless pressure sensor into lung artery via catheter. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has tachycardia induced cardiomyopathy with reduced ejection fraction (38%) and congestive heart failure. In this circumstance therapy change based on data obtained from a CardioMEMS device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. 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 insertion of wireless pressure sensor into lung artery via catheter have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of wireless pressure sensor into lung artery via catheter (CardioMEMS device).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rinvoq tablets.
You asked the Plan to pre-approve Rinvoq tablets. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says Rinvoq tablets are not covered under the enrollee's Medicare Part B benefit.
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 Rinvoq tablets.
Benefits for Rinvoq 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Beovu.
You asked the Plan to pre-approve Beovu. You say that the enrollee needs to switch to Beovu. The Plan denied your request. The Plan says the enrollee has not tried and failed bevacizumab (Avastin) as required by step therapy rules.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Beovu. Our reviewer says that coverage criteria for Beovu have not been met. Our physician reviewer found the documentation does not support that the enrollee has tried Avastin (bevacizumab), or that Avastin would likely be less effective, or would likely have adverse effects for the enrollee 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 Beovu have not been met. Therefore, we decided that the Plan does not have to pre-approve Beovu.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the two resin-based composites provided on June 19, 2019.
You asked the Plan to pay for the second resin-based composite. You say that the Plan told you that you had 100% dental coverage and 4 $500 quarterly allowances. You also say that the crown you had put in required two to three visits, but the dentist billed the insurance company in one bill, exceeding your quarterly $500 coverage. The Plan denied your request. The Plan says that the maximum allowed for the quarterly max of the 2nd quarter had been met.
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 second resin-based composite when the services are medically necessary and reasonable. The records show that you received two resin-based composites on June 19, 2019. These services are considered fillings and are listed as a covered service under the quarterly $500 allowance for comprehensive dental services in the Evidence of Coverage. The records did not show that you had exceeded this quarterly benefit at the time of this service. It is the Plan's responsibility to gather and forward all of the necessary information for to the IRE.
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the second resin-based composite have been met. Therefore, we decided that the Plan has to pay for the two resin-based composites provided on June 19, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you want to go to rehab until you regain your strength. The Plan denied your request. The Plan says that your needs can be met at a lower level of care such as with home health care.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.