Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you are unable to walk on your own and need more
therapy. The Plan denied your request. The Plan says the stay is not medically necessary.
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 were admitted for
seizures and a knee laceration. Medical problems are stable. There are no complex nursing or rehabilitation
needs. 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from April 1, 2021, to April 26, 2021.
You asked the Plan to waive the copayment for a SNF stay. You say that you were incoherent and could not comprehend your benefits at the time. You state that had you known you would owe a copayment you would have insisted on leaving sooner. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $0 copayment for days 1-20 and a $160 copayment for days 21-44 for SNF care.
You had a SNF stay from March 31, 2021, to April 26, 2021. You are not being charged a copayment for days 1-20 (March 31, 2021, to April 19, 2021). You are responsible to pay a $160 copayment for days 21-26 (April 20, 2021, to April 25, 2021). The total amount you owe is: $160 (copayment) x 6 (SNF days) = $960. You have been asked to pay the total copayment amount of $960 for a SNF stay. A SNF stay falls within the SNF care benefit 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 a SNF stay provided from April 1, 2021, to April 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pradaxa for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under Part B.

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 Pradaxa for the enrollee.

Benefits for this drug 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided from March 11, 2021, to April 9, 2021.
You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $40 copayment for outpatient rehabilitation services. You received outpatient rehabilitation services from March 11, 2021, to April 9, 2021, for a total of 3 services. The total amount you owe is: $40 (copayment) x 3 (outpatient rehabilitation services) = $120.
You have been asked to pay the total copayment amount of $120 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation services benefit 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 outpatient rehabilitation services provided from March 11, 2021, to April 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a limited oral evaluation (D0140), surgical implant placement (D6010), therapeutic parenteral drugs (D9610), guided tissue regeneration (D4266), sinus augmentation (D7951) and a bone replacement graft (D7953).

You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered by your dental 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 limited oral evaluation (D0140), surgical implant placement (D6010), therapeutic parenteral drugs (D9610), guided tissue regeneration (D4266), sinus augmentation (D7951) and a bone replacement graft (D7953).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for nuclear medicine provided on April 14, 2021.

You asked the Plan to waive the copayment for nuclear medicine. You say that you feel that the charges are incorrect. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $100 copayment for diagnostic radiology. 

You have been asked to pay the allowed amount of $91.20, which is less than the $100 copayment for nuclear medicine. Nuclear medicine falls within the outpatient diagnostic tests and therapeutic services and supplies benefit 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 nuclear medicine provided on April 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).

You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.

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 Prolia. Our reviewer says that Prolia (J0897) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial of drug Zoledronic Acid before they will approve the requested drug. Our reviewer found that the enrollee has not tried and failed the required drug. Our physician reviewer also found that there is no documentation provided indicating that the Plan's required drug will likely be less effective and/or likely have adverse effects 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87150, 87481, 87500, 87511, 87529, 87640, 87641, 87651, 87653, 87798, 87801) provided on April 12, 2021.

You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was a screening service.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87150, 87481, 87500, 87511, 87529, 87640, 87641, 87651, 87653, 87798, 87801) provided on April 12, 2021.
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 this treatment is recommended for the enrollee and you believe the Keytruda should be approved for coverage. The Plan denied your request. The Plan says the combination of Keytruda with Lynparza does not meet oncology standards for adequate evidence of safety and efficacy for this use.

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 reviewer says that Keytruda is not medically reasonable and necessary for the enrollee. Our physician reviewer found the requested use of Keytruda in combination with Lynparza is not FDA-approved for the enrollee's diagnosis. Our reviewer found that the use of Keytruda is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services approved medical journal. Our physician reviewer also found that the use of Keytruda is not listed as not indicated, not supported or not recommended in any of the compendia.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement pair of eyeglasses for the current calendar year.
You asked the Plan to pre-approve new eyeglasses. You say that you ordered glasses earlier in the year, but you are dissatisfied with the services provided. The eyeglasses are not the material you ordered, the prescription is wrong, and they do not fit. The Plan denied your request. The Plan says you exhausted your supplemental vision benefits in January when you purchased your eyeglasses. Only one pair of glasses can be covered per plan year, and you advised the Plan that you did not return the eyeglasses to the in-network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one pair of eyeglasses per year. We looked at the file and the Plan's rules. You have exhausted your benefits and have already received a pair of eyeglasses during the 2021 calendar year. Documentation shows that you advised the Plan that you still have this pair of glasses, and they have not been returned to the provider. Based on this information, we decided that the Plan's rules for coverage of new eyeglasses have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement pair of eyeglasses for the current calendar year. You may wish to contact and work with the provider and the Plan directly to see if the glasses can be returned and replaced or be refitted and provided with a corrected prescription, but the Plan does not have to cover a second pair of eyeglasses for the current year.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for respiratory pathogen panel testing provided on April 20, 2021.
You asked the Plan to pay for panel testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this test is not a Medicare benefit for the diagnoses listed and was performed for screening purposes.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, respiratory pathogen panel testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for respiratory pathogen panel testing provided on April 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic continuous glucose monitor (CGM) supplies provided on March 18, 2021.
You asked the Plan to pay for therapeutic CGM supplies. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these supplies is correct, because these supplies were provided through unsolicited cold calling.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM supplies have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic continuous glucose monitor (CGM) supplies provided on March 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compression device (E0673) and segmental gradient pressure pneumatic appliance (E0675).

You asked the Plan to pay for the pneumatic compression device and appliance. You say that the DME equipment was prescribed by the doctor and was issued to the enrollee for use during their surgery. You are not contracted with the facility or the prescribing physician and do not receive payment from either provider. The Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Based on this information, we decided that Medicare rules for coverage of the pneumatic compression device and appliance have not been met. Therefore, we decided that the Plan does not have to pay for pneumatic compression device (E0673) and segmental gradient pressure pneumatic appliance (E0675).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee needs to improve with therapies before going home. The Plan denied your request. The Plan says the enrollee does not require an intensive multidisciplinary approach to daily therapy.

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 physician reviewer found that the enrollee was admitted to the acute hospital for surgical repair of a hip fracture. Her medical problems are stable. There are no complex nursing needs. The enrollee does not require treatment by multiple therapies in 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.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does
not require daily skilled therapy services on an inpatient basis.
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 services. Our physician reviewer
found that the enrollee's current level of function is at an independent assist level for sit-to-stand, and
ambulation using a rolling walker. There are no documented skilled nursing needs. At the current level of
function, she does not require daily skilled therapies in an inpatient 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you have swelling and pain in both your feet and knees. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace (L1832, L2397) provided on February 5, 2021.
You asked the Plan to pay for a knee brace. You say that this is supported by the documentation. The Plan denied your request. The Plan says the submitted records are not sufficient to support these items.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The submitted medical records document that the enrollee was functional in regard to basic activities of daily living on her regimen prior to receiving the items at issue. The records do not reference the items at issue or indicate that they are necessary. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a knee brace (L1832, L2397) provided on February 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planing, four or more teeth per
quadrant (D4341) provided February 17, 2021.

You asked the Plan to pay for the dental services. You say that scaling and root planing had previously been
completed in another office in June of 2020. It is your recommendation that scaling and root planing is
completed in your office. The Plan denied your request. The Plan says this service exceeds the benefit
limitation.

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. This service is covered once
every plan year. The records show that this service was previously provided June 12, 2020 and June 15, 2020.

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 pay for
periodontal scaling and root planing, four or more teeth per quadrant (D4341) provided February 17, 2021.