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

We decided that the Plan does not have to pay for portable oxygen (E1390) that you purchased on January 28, 2021.
You asked the Plan to pay for the portable oxygen. You say that you would like reconsideration because the portable oxygen helps you to perform daily tasks and you have a prescription from your physician. The Plan denied your request. The Plan says Medicare and the plan will only cover the rental of oxygen devices from approved in-network suppliers and will not cover the cost of purchasing a portable oxygen concentrator.
The Plan must follow Medicare rules. Medicare rules say that payment is not made for purchases of this type of equipment We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the portable oxygen have not been met. Specifically, the record indicates that you are requesting payment for oxygen equipment that you purchased. Neither Medicare nor the Plan cover purchased oxygen equipment. Therefore, we decided that the Plan does not have to pay for portable oxygen (E1390) that you purchased on January 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Supartz FX (J7321).
You asked the Plan to pre-approve Supartz FX. You say that the enrollee has failed conservative treatment with Tramadol and Corticosteroid injections. You also say that the enrollee is unable to take non-steroidal anti-inflammatory drugs due to blood thinners. The Plan denied your request. The Plan says step therapy rules for the requested treatment have not been 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 Supartz FX. Our reviewer says that the requested drug is not medically necessary in this case. Our physician reviewer found that the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the Plan, requires that these be trialed first. The documentation does not outline contraindications or reasons why these alternative medications were not considered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz FX have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Supartz FX (J7321).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency transportation; taxi (A0100) beyond the Plan's 24-trip limit.

You asked the Plan to pre-approve additional routine transportation. You say that you have multiple medical appointments and need transportation to get to them. The Plan denied your request. The Plan says routine transportation is not covered beyond 24 trips.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 trips per year. 

We looked at your request, the records in the case file, and the rules. The Plan provided documentation showing that you have used your 24 trips. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional non-emergency transportation; taxi (A0100) beyond the Plan's 24-trip limit.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp Injection.

You asked the Plan to pre-approve Aranesp Injection, darbepoetin alfa, 1 microgram (non-esrd use) (J0881). You say that you would like to treat the enrollee with this drug. The Plan denied your request. The Plan says the enrollee has not first tried and failed Retacrit therapy for at least two consecutive months.

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 Aranesp Injection, darbepoetin alfa, 1 microgram (non-esrd use) (J0881). Our reviewer says that the drug is not reasonable and medically necessary. Our physician reviewer found based on the medical records provided the patient has not tried and failed the required drug. Based on the medical records provided there is no indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the patient. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp Injection, darbepoetin alfa, 1 microgram (non-esrd use) (J0881) have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp Injection.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Aurora Zip Ultra procedure.

You asked the Plan to pre-approve the Aurora Zip Ultra procedure. You say that this request is medically necessary. The Plan denied your request. The Plan says this procedure is considered experimental/investigational.

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 Aurora Zip Ultra procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a review of the current medical literature indicates that this service is considered experimental and investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature. The review has determined that the items/services at issue in this case are 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 Aurora Zip Ultra procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Aurora Zip Ultra procedure.
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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a Dexcom G6 CGM.
You asked the Plan to pre-approve the Dexcom G6 CGM. You say that the Dexcom G6 plays an important role in the control of the enrollee's type 1 diabetes. The Plan denied your request. The Plan says that non-therapeutic CGMs are not payable by Medicare and not are a covered benefit.
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. Medicare rules also say that therapeutic CGMs are considered reasonable and necessary for enrollees with diabetes who meet criteria referenced above. 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 give a valid denial rationale since the requested CGM is Food and Drug Administration (FDA) approved as therapeutic. The enrollee also meets the above criteria for coverage of a CGM. Therefore, we decided that the Plan has to pre-approve a Dexcom G6 CGM.
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: Testing
Decision: Favorable

We decided that the Plan has to pre-approve high intensity focused ultrasound (HIFU) therapy (55880).

You asked the Plan to pre-approve HIFU therapy. You say that there is ample evidence that HIFU treatment for prostate cancer is an appropriate and reasonable therapy in properly selected patients like the enrollee. The Plan denied your request. The Plan says that the criteria has not been met because the enrollee's prostate cancer is not a recurrence and the enrollee has not been previously treated with radiation therapy.

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 HIFU therapy. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found High Intensity Focused Ultrasound (HIFU) treatment of the prostate is neither experimental nor investigational. HIFU was FDA approved for prostate gland ablation (primary and salvage) October 9, 2015. HIFU of the prostate (HCPCS code C9747) has Medicare coverage as of July 1, 2017. Numerous clinical studies cited below have demonstrated treatment efficacy that is comparable to surgery or radiation but with a much lower risk of side effects such as impotence, incontinence and bowel injury.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of HIFU therapy have been met. Therefore, we decided that the Plan has to pre-approve high intensity focused ultrasound (HIFU) therapy (55880).

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 cancer treatments associated with a clinical trial.
You asked the Plan to pre-approve cancer treatments associated with a clinical trial. You say that the services are necessary. The Plan denied your request. The Plan says since the member is enrolled in a clinical trial, the requested drug is deemed a routine cost.
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 cancer treatments associated with a clinical trial 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 cancer treatments associated with a clinical trial.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the repair, extensor tendon, finger, primary or secondary; without free graft, each tendon (26418) and the arthrotomy, with exploration, drainage, or removal of loose or foreign body; metacarpophalangeal joint (26075) rendered by the out-of-network (OON) provider on June 4, 2020.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 repair, extensor tendon, finger, primary or secondary; without free graft, each tendon (26418) and the arthrotomy, with exploration, drainage, or removal of loose or foreign body; metacarpophalangeal joint (26075) rendered by the out-of-network (OON) provider on June 4, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed 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 SNF care. Our reviewer says that the services are medically necessary. Our physician reviewer found you qualify for ongoing SNF coverage after August 29, 2021. You have documented skilled nursing needs. You do not have documented skilled therapy needs, as you are performing at such a level that rehabilitative service can be provided at a lower level of care. Together, and in the absence of any other plan to provide the needed services, SNF coverage is medically necessary and reasonable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

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 pay for a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).

You asked the Plan to pay for a pneumatic compression device and appliance. You say that you respectfully disagree with this determination and ask for review of the enclosed documentation supporting medical necessity of the requested equipment. 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 pay for a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on April 8, 2021.
You asked the Plan to pay for the eye refraction. You say that you have had these test often. The Plan denied your request. The Plan says refractions are part of a "Routine" eye exam and your claim is for cataract and glaucoma, which are medical diagnosis, so the refraction is not a covered service.
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.
We looked at the file and the Medicare rules. The file shows that you received an eye exam for a Medicare-covered eye condition and not a routine eye exam. The file shows that this exam was for a refraction. Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on April 8, 2021.
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 your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

You do not require treatment by multiple therapies, including either physical therapy or occupational therapy,
and an intensive rehabilitation therapy program. While the documentation does support a need for physical
and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation
program. There is not a reasonable expectation that you 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyoPro 2 Motion G orthotic device (L8702).

You asked the Plan to pre-approve the orthotic device. You say that given that traditional therapies have been tried and failed, the enrollee has been referred for myoelectric orthotic restoration. The Plan denied your request. The Plan says this item is considered experimental and investigational. There is lack of evidence demonstrating an impact on improved health outcomes.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve MyoPro 2 Motion G orthotic device (L8702).