Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Wellbutrin.
You asked the Plan to pre-approve Wellbutrin. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered 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 Wellbutrin.
Benefits for Wellbutrin 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee.

You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says the Centers for Medicare & Medicaid Services (CMS) website shows the enrollee was enrolled in hospice from. In accordance with Medicare guidelines, the provider needs to bill Original Medicare, using the proper modifiers, for services rendered. Per the regulations above, the members claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. It is the providers responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower chair.You asked the Plan to pre-approvea shower chair. You say that you need a replacement custom shower chair.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup on tooth #21 and #28.
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan
denied your request. The Plan says this is not a covered benefit.
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 core
buildup on tooth #21 and #28.
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 you disagree with the denial. The Plan denied your
request. The Plan says the services are 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 above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not medically necessary. 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. He was admitted for respiratory failure and myocardial
infarction associated with a COVID 19 infection. His medical conditions are now stable and he has no complex
nursing or rehabilitation needs. He does not require treatment by multiple therapies, including either physical
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record
documents a need for physical and occupational therapy, it does not document a need for an intensive
rehabilitation program. There is not a reasonable expectation that the 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on September 4,
2020.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says
these services were not an emergency, urgently needed care or out-of-area dialysis, and an authorization was
not obtained prior to the services being rendered.
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 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 subsequent nursing facility care provided on September 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesubmucosal ablation of the tongue base.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the 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 these services. Our reviewer says that the services arenot medically necessary. Our physician reviewer found the enrollee has sleep apnea and the standard treatment for this condition is continuous positive airway pressure (CPAP)/automatic positive airway pressure (APAP) therapy. She has not had any prior treatments. The clinical value and effectiveness of radiofrequency ablation in the setting of sleep apnea has not been demonstrated in the peer-reviewed literature. The requested submucosal ablation of the tongue base is not the standard of care for the enrollee's condition and is not reasonable or 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvesubmucosal ablation of the tongue base.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on May 22, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says your PCP
never referred or directed you to see this provider and the IPA has no record of an approved authorization for
this 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 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 did not pre-approve the
physician's services. 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 physician's services provided on May 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve occupational therapy to be provided by the out-of-network provider.
You asked the Plan to pre-approve the occupational therapy. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve occupational therapy to be provided by the out-of-network 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 enrollee needs a higher level of care. The Plan
denied your request. The Plan says the services are 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 above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not medically necessary. 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. He is medically stable and has no complex nursing or
rehabilitation needs. He does not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a
need for physical and occupational therapy, it does not document a need for an intensive rehabilitation
program. There is not a reasonable expectation that the 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: Unfavorable

We decided that the Plan does not have to pre-approveincontinence supplies.You asked the Plan to pre-approveincontinence supplies. You say that this is medically necessary.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approveincontinence supplies
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation care you received August 21, 2020, to August 28, 2020.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you disagree with the copayment and would like it waived. The Plan denied your request. The Plan says the copayment has applied correctly in this case.
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 $325 copayment per admission for inpatient hospital care. You have been asked to pay a $325 copayment for the inpatient hospital care. The service provided falls within the inpatient hospital 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 the inpatient rehabilitation care you received August 21, 2020, to August 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies coded as A4520.
You asked the Plan to pre-approve incontinence supplies. You say that you have a lot of medical issues making
you not able to get to the restroom on time. You need the adult diapers so that you are able to do every day
activities to survive. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies coded as
A4520.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe cardiovascular risk assessment panel provided on August 7, 2020.You asked the Plan to pay forthe cardiovascular risk assessment panel. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, arenot covered.The cardiovascular risk assessment panel  at issue in this appeal was 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 pay forthe cardiovascular risk assessment panel provided on August 7, 2020
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay foroccupational therapy services (97110, 97022, 97140) provided May 29, 2018.You asked the Plan to pay forthe therapy services. You say that the services were medically necessary.The Plan denied your request. The Plan says the claim was not filed timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for the therapy services was not filed until August 18, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay foroccupational therapy services (97110, 97022, 97140) provided May 29, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe core buildup (D2950) and occlusal guard-full arch (D9944).You asked the Plan to pre-approvethe core buildup and occlusal guard-full arch. You say that the service is medically necessary.The Plan denied your request. The Plan says these services are 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.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-approvethe core buildup (D2950) and occlusal guard-full arch (D9944).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor on July 26, 2020.
You asked the Plan to pay for the glucose monitor. You say that the claim should be paid. The Plan denied your
request. The Plan says the member reported that the claim was the result of telemarketing so the claim should
be denied.
The rules say for Medicare to consider coverage and payment for any item or service, the information
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical
documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a
covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary
and conducted a face-to-face assessment.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the durable medical equipment have not been met. Specifically, medical records do not support a
prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an
appropriate use of telehealth. This was a telemarketing scam. The enrollee did not order the DME. The
submitted consultation notes do not support that a physical examination was performed. The information
submitted does not confirm that Medicare coverage criteria have been met.
A review of the file does not show that the service was provided in an authorized originating site. This means
that the DME is not a covered service under the Medicare program. Therefore, we decided that the Plan does
not have to pay for the glucose monitor on July 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAstigmatism correcting function intraocular lens (AC-IOL) (V2787).You asked the Plan to pre-approveAC-IOL. You say that the service is medically necessary.The Plan denied your request. The Plan says the service is not a covered benefit.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 these services when listed as a covered benefit in the EOC. Medicare only covers a standard lens during cataract surgery. The service at issue is an Astigmatism correcting function intraocular lens (V2787) also known as an AC-IOL. This is an upgraded lens and Medicare does not cover it. The Plan's supplemental benefit also does not cover it.While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL.We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for coverage of AC-IOL have not been met.Specifically, this service is not a covered benefit of either Medicare or the Plan's supplement benefits.Therefore, we decided that the Plan does not have to pre-approveAstigmatism correcting function intraocular lens (AC-IOL) (V2787).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the exchange nephrostomy catheter services coded 50435
provided on August 12, 2020.
You asked the Plan to pay for the exchange nephrostomy catheter services. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 CPT Code Manual definition of code 50435 is exchange nephrostomy catheter, percutaneous,
including a diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (e.g., ultrasound
and/or fluoroscopy) and all associated radiological supervision and interpretation.
We find that CPT code 50435 is not supported in the medical record. Specifically, this service was billed with
unspecified diagnosis codes but was billed with modifier RT (right side) indicating the left side. Therefore, the
services were billed with inappropriate diagnosis codes. Based on this information, we decided that Medicare
rules for coverage of the exchange nephrostomy catheter services have not been met. Therefore, we decided
that the Plan does not have to pay for the exchange nephrostomy catheter services coded 50435 provided on
August 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea group 3 power wheelchair and related accessories.You asked the Plan to pre-approvea group 3 power wheelchair and related accessories. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says you do notmeet criteria for the requested item.The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to:1. A neurological condition;2. Myopathy; or3.Congenital skeletal deformity.The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity.Therefore, we decided that the Plan does not have to pre-approvea group 3 power wheelchair and related accessories
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Freestyle Libre continuous glucose monitor (CGM).You asked the Plan to pre-approvea Freestyle Libre CGM. You say that this is medically necessary.The Plan denied your request. The Plan says the criteria for coverage have not been met.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs areconsidered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.We looked at the file and Medicare rules. The documentation does not indicate that the enrollee performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, and requires frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met.Therefore, we decided that the Plan does not have to pre-approvea Freestyle Libre continuous glucose monitor (CGM)