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

We decided that the Plan does not have to pay for the pneumatic compression device coded as E0675.
You asked the Plan to pay for the pneumatic compression device coded as E0675. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that a PCD coded as E0675 is not eligible for coverage. We looked at the file and Medicare rules. Based on this information, we decided that Medicare does not provide coverage for the pneumatic compression device coded as E0675. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device coded as E0675.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide non-therapeutic continuous glucose monitoring system supplies.

You asked the Plan to provide non-therapeutic continuous glucose monitoring system supplies. You say that this system communicates with the enrollee's insulin pump. The Plan denied your request. The Plan says this product is not Medicare eligible.

The Plan must follow Medicare rules. Medicare rules say Continuous Glucose Monitor systems that have not been reviewed and listed on the Product Classification List for HCPCS code K0554 will be denied as incorrect coding. 

We looked at the file and Medicare rules. The requested supplies are for a system that is not covered by Medicare. Therefore, we decided that the Plan does not have to provide non-therapeutic continuous glucose monitoring system supplies.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid;
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (CPT code
64483), for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your
request. The Plan says the service is not 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 service. physician reviewer found
the criteria for lumbar injection therapy not met. There is no documentation of adequate conservative measures
to include recent physical therapy (PT) for back pain.
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 service have not been met. Therefore, we decided that the Plan does not
have to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging
guidance (fluoroscopy or CT), lumbar or sacral, single level (CPT code 64483), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve comprehensive BRCA 1 and 2 testing with BART.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered screening and specifically excluded by Medicare.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The test at issue in this appeal, the services, is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve comprehensive BRCA 1 and 2 testing with BART.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PT and OT to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve the PT and OT to be provided by the requested out-of-network provider. You say that the enrollee is not able to get to either of the two in-network providers. The Plan denied your request. The Plan says the services are available with a Plan provider.

The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. 

The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is not providing these services and is not making arrangements to provide these services. Therefore, we decided that the Plan does not have to pre-approve PT and OT to be provided by the requested out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic casts (D0470), complete dentures (D5110, D5120) and occlusion analysis (D9950) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the dental services. You say that you want to see this provider because you have heard good things about them. You feel that you will receive better care from this provider. The Plan denied your request. The Plan says out-of-network dental care is not covered.
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 only covers dental services that are provided in-network. Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from out-of-network providers are not covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve diagnostic casts (D0470), complete dentures (D5110, D5120) and occlusion analysis (D9950) to be provided by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that the enrollee would benefit from care in the SNF. The Plan denied your request. The Plan says daily skilled services are not required.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital due to pneumonia and sepsis. Therapy notes show that the enrollee is a high fall risk. He is ambulating up to 125 feet with a rolling walker and contact guard assistance. The patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The patient's high functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this patient does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you believe it is clinically clear according to the records that a leg pump is excluded, and the requirement is for the appropriate home compression device due to this enrollee's clinical condition. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
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 Keytruda is a less toxic choice. The Plan denied your request. The Plan says the drug does not meet the coverage indication to be considered medically necessary.
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 Keytruda. Our physician reviewer found that the enrollee has stage III renal cancer. The requested use of Keytruda is not FDA-approved for the enrollee's diagnosis. The only approved adjuvant treatment is Sutent. Keytruda for stage III renal cancer is not compendia based or literature supported. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty walker.

You asked the Plan to pre-approve the walker. You say that this is medically necessary. The Plan denied your
request. The Plan says this is covered for beneficiaries who weigh more than 300 pounds.

The Plan must follow Medicare rules. Medicare rules say that a heavy-duty walker is covered for enrollees who
weigh more than 300 pounds.

There is no documentation showing that you weigh more than 300 pounds. Based on this information, we
decided that Medicare rules for coverage of the walker have not been met. Therefore, we decided that the Plan
does not have to pre-approve a heavy-duty walker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seating system with electrical connection (E1007, E2311) and a headrest (E0955).
You asked the Plan to pre-approve a power seating system with electrical connection and headrest. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that the power seating system and headrest are subject to the criteria listed in the Medicare rules section. 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 power seating system with electrical connection and headrest. Our reviewer says that the requested items are not medically necessary and reasonable. Our physician reviewer found that the headrest (E0955) criteria have not been met per the Local Coverage Determination (LCD): Wheelchair Seating (L33312) as the patient does not meet the LCD requirements for the headrest. The documentation does not reveal that there are significant postural asymmetries. In addition, a power seating system (E1007, E2311) is not medically necessary as the criteria per Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792) and Local Coverage Article: Power Mobility Devices - Policy Article (A52498). The documentation does not reveal that the patient has spasticity, utilizes intermittent catheterization, or is at high risk of skin breakdown. As the power seating is not medically necessary the connector coded with E2311 is 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 a power seating system with electrical connection and headrest have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seating system with electrical connection (E1007, E2311) and a headrest (E0955).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional features for a prosthetic leg (L5828, L5845, L5848, L5856, L5981).
You asked the Plan to pre-approve the features. You say that this is medically necessary. The Plan denied your request. The Plan says a request for an advanced K3 knee and foot does not meet the Medicare criteria as being reasonable and 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 features. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the physician documentation does not support that you are a K3 ambulator, or has the potential for ambulation with variable cadence. Th physician documentation does not reveal that you have the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. 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 features have not been met. Therefore, we decided that the Plan does not have to pre-approve additional features for a prosthetic leg (L5828, L5845, L5848, L5856, L5981).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vision services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve vision services. You say that you need to be evaluated by retina specialists. The Plan denied your request. The Plan says these services are not covered because they are being requested OON and there is no record of a referral or of a need that cannot be met 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 vision services to be provided by an out of network (OON) provider.
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.

You asked the Plan to pre-approve IRF 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 IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

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 the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but
there is no documented need for an intensive rehabilitation program. Medically necessary services can be
provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to waive the additional payments for the filling on a front tooth for tooth # 8. We decided that the Plan does not have to waive the additional payments for the filling for tooth # 15.
You asked the Plan to waive the additional payments for the filling on a front tooth for tooth # 8. You say that you were billed $500 for the services that you received. You say that you should only be responsible for 50%, or $250. You also say that the provider billed you for an additional $99. The Plan denied your request. The Plan says that multi-surface white fillings will be processed as a silver filling. The Plan says that when a procedure is given an alternate benefit, the member is responsible for the difference in allowed amounts between the 2 services. The Plan also says that there is a 50% coinsurance for Class 2 Basic Services, including fillings.
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 fillings when the services are medically necessary and reasonable.
We decided that the Plan has to waive the additional payments for the filling for tooth # 8.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the filling on a front tooth for tooth # 8 have been met. Specifically, the Evidence of Coverage clearly states that white fillings on an anterior (front) tooth are covered once every 24 months with a 50% coinsurance Therefore, we decided that the Plan has to waive the additional payments for the filling for tooth # 8.
We also decided that the Plan does not have to waive the additional payments for the filling for tooth # 15.
Though the Plan offers a dental benefit in excess of Medicare coverage and white fillings for back teeth are listed as a covered service, they are processed with an alternate benefit of a silver filling. The Evidence of Coverage specifically states that if a method of treatment is more costly than is customarily provided, benefits will be paid on the least costly method of treatment, and you will be responsible for the remaining balance. Therefore, we decided that the Plan does not have to waive the additional payments for the filling for tooth # 15.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a platelet rich plasma injection.
You asked the Plan to pre-approve injection, platelet rich plasma, any site, including image guidance, harvesting and preparation when performed (0232T). You say that this shot could work better and more effectively than the surgery with less recovery time. The Plan denied your request. The Plan says the records do not indicate you have chronic non-healing diabetic, venous and/or pressure wounds.
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 injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed (0232T). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found PRP injection therapy for wounds remains experimental at this time. More research is needed to show safety and efficacy of PRP injection for wound healing. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed (0232T) have not been met. Therefore, we decided that the Plan does not have to pre-approve a platelet rich plasma injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve speech pathology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve speech pathology services. You say that you would like to have these services approved for an out-of-network provider. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 speech pathology services to be provided by an out of network (OON) provider.