Persius/hicric huggingface dataset:
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 the medication is 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 Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Keytruda. Our reviewer says that the medication is not medically necessary. Our physician reviewer found Pembrolizumab (Keytruda) is not considered a standard of care in the treatment of noninvasive bladder cancer. Use is not supported by major drug compendia or the medical literature for this indication. Guidelines support the use of several other chemotherapeutic agents in lieu of bacille Calmette-Guerin (BCG) during the worldwide shortage of this medications. The service 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 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 Phillips Life Alert system.
You asked the Plan to pre-approve a Phillips Life Alert system.. You say that you were told this would be
covered. The Plan denied your request. The Plan says this item is excluded from coverage under Medicare
rules.
The Plan must follow Medicare rules. Medicare rules say that Telephone Alert Systems are emergency
communications systems and do not serve a diagnostic or therapeutic purpose. These systems are not covered
by Medicare.
We looked at the file and Medicare rules. The item at issue does not serve a medical purpose and is not
covered. Based on this information, we decided that Medicare rules for coverage of a Phillips Life Alert
system. have not been met. Therefore, we decided that the Plan does not have to pre-approve a Phillips Life
Alert system.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health physical therapy visits.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the therapy note dated December 7, 2020 states that the enrollee was standing upon arrival and performing 15 standing exercises. She had good exercise tolerance. The records do not support that she has continued skilled therapy needs. The requested additional home health PT 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-approve additional home health physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided on September
14, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that this item was medically necessary for
the enrollee. The Plan denied your request. The Plan says there is no evidence that the prescribing physician
ever saw the member.
The Plan follows Medicare rules. Medicare rules say that a spinal orthosis is subject to the medical necessity
criteria as 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 pay for the lumbar-sacral orthosis. Our reviewer
says that the orthosis was not medically necessary and reasonable. Our physician reviewer found an appropriate
history and a physical examination of the back would reasonably be required to adequately assess whether the
coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the
lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is
insufficient documentation of a credible evaluation and a credible physical examination of the back.
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 lumbar-sacral orthosis have not been met. Therefore, we decided that the
Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided on September 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lupron Depot (J9217).

You asked the Plan to pre-approve Lupron Depot. You say that the services are necessary. The Plan denied your request. The Plan says they are not responsible for covered routine costs associated with clinical trials.

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 Lupron Depot 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 Lupron Depot (J9217).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 15.
You asked the Plan to pre-approve the dental service. You say that the core build up is medically necessary. The Plan denied your request. The Plan says core build up is not listed as a covered service.
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, core build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 15.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vehicle scooter lift.
You asked the Plan to pre-approve a vehicle scooter lift. You say that the item is necessary. The Plan denied your request. The Plan says the requested item is not primarily medical in nature. Therefore, coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a vehicle scooter lift.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the crown (D2740) provided on October 19, 2020.
You asked the Plan to pay for the crown. You say that the crown was necessary in order to save the enrollee's tooth. The Plan denied your request. The Plan says that this service is preventive in nature and is not covered.
The rules say that the health plan must provide you with a clear and accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under the enrollee's plan contract including applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits. The rules also say that Medicare plans must make reasonable and diligent efforts to gather and forward information to the IRE. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have been met. Digital quality x-rays were not submitted with this case in order to determine the necessity of the crown. The EOC also lists crown (D2740) as a covered benefit, but does not indicate any criteria regarding how the crown would or would not be covered. Therefore, we decided that the Plan has to pay for the crown (D2740) provided on October 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two endosteal implants and two semi-precision attachment abutments.

You asked the Plan to pre-approve the endosteal implants and semi-precision attachment abutments. The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit plan.

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 two endosteal implants and two semi-precision attachment abutments.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the member needs skilled nursing service to help her return home. The Plan denied your request. The Plan says that the continuation of skilled services can be provided on an intermittent basis on an outpatient basis, in a long-term care facility, or at the home with home health care services.
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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Guardian Sensor 3.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that CGM supplies or accessories billed separately will be denied as unbundling. 

We looked at the file and Medicare rules. The requested services are a Guardian Sensor 3. CGM supplies are not covered when requested as separate items. Furthermore, the Guardian system is not an approved CGM with Medicare. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Guardian Sensor 3.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer device.
You asked the Plan to pre-approve an interspinous spacer device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an interspinous spacer device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer device is experimental at this time. More research is needed to show safety and efficacy. High failure rates have been reported with interspinous process distraction devices. Open laminectomy remains the gold standard procedure for lumbar decompression. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an interspinous spacer device have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling (D4342) for the upper right and lower left quadrants.

You asked the Plan to pre-approve the dental services. You say that you have had a number of health problems. You say that you have waited a year and a half. You say that your dentist said you needed scaling for 2 quadrants. You say that you were told you can only have 1 every 3 years. You say that you had them done in 2020 but they were not done correctly. You say that the dentist is now trying to correct that error. You say that you need these services so that you can get a cleaning. You also say that you have a very low income. The Plan denied your request. The Plan says periodontal scaling and root planing is covered once per quadrant every 3 years. The Plan says that the frequency limit for this service has been reached.

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 frequency limit for this service has been reached. The record shows that the Plan paid for scaling and root planing for the upper right and lower left quadrants. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling (D4342) for the upper right and lower left quadrants.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care.

You asked the Plan to waive the copayment for the inpatient hospital care. You say that the copayment should
be waived. The Plan denied your request. The Plan says the correct amount was applied.

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
per day copayment for days 1-5 of inpatient care.

You have been asked to pay a copayment of $1,625 for 5 days of inpatient hospital care. 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 inpatient hospital care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for bone density scan of axial bones like hip, pelvis and spine (77080) provided August 14, 2020.
You asked the Plan to pay for bone density scan. You say that the medical records should support the medical necessity of the service in dispute. The Plan denied your request. The Plan says the procedure/revenue code is inconsistent with the enrollee's age
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 77080 is Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites. We find that CPT code 77080 is not supported in the medical record. Specifically, the claim was billed with a diagnosis of Z13.820, which is not listed as a covered diagnosis for bone mass measurement. A corrected claim has not been submitted. Based on this information, we decided that Medicare rules for coverage of bone density scan have not been met. Therefore, we decided that the Plan does not have to pay for bone density scan of axial bones like hip, pelvis and spine (77080) provided August 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for dental services with an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says care must be received from an in-network contracted 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 a referral for dental services with an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tymlos.
You asked the Plan to pre-approve Tymlos. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 Tymlos.
Benefits for Tymlos may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) supply allowance
(K0553) provided on September 14, 2020.
You asked the Plan to pay for a CGM supply allowance. You say that the service is medically necessary. The
Plan denied your request. The Plan says insufficient documentation was submitted.
The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for a CGM supply allowance. Our reviewer says
that the service is not medically necessary. Our physician reviewer found it is not clear from the documentation
that the enrollee uses a DME receiver for a therapeutic CGM.
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 CGM supply allowance have not been met. Specifically, there is no evidence
that the enrollee uses a DME receiver for a therapeutic CGM. This means the item is requested is not medically
necessary or reasonable. Therefore, we decided that the Plan does not have to pay for a continuous glucose
monitor (CGM) supply allowance (K0553) provided on September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for teeth # 11.
You asked the Plan to pre-approve the dental service. You say that the crown is necessary. The Plan denied your request. The Plan says 2 crowns are covered per calendar year. The Plan also says that the frequency limit has been reached.
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 frequency limit of 2 crowns per calendar year has been reached. The record shows that the Plan previously approved the crowns for teeth # 29 and 31 on January 26, 2021. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for teeth # 11.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve echocardiography (93306).

You asked the Plan to pre-approve the echocardiography. You say that you would like reconsideration because
the echocardiography is medically necessary. The Plan denied your request. The Plan says that imaging is not
supported without results of a recent electrocardiogram that supports imaging.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the echocardiography. Our reviewer
says that the requested items/services are considered medically reasonable and necessary in this case. Our
physician reviewer found the member has significant baseline abnormalities on the electrocardiogram,
exertional symptoms and has not had a recent cardiac ultrasound study.

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 echocardiography have been met. Therefore, we decided that the Plan has to
pre-approve echocardiography (93306).

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.