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

We decided that the Plan does not have to pre-approve an electronic connection, expandable controller, harness and power seat elevation feature. You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that there is not a medical need to control these power options through the joystick. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature. 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 electronic connection, expandable controller and harness. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. These accessories are convenience items, and are not required for optimum wheelchair functioning. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these items. 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 an electronic connection, expandable controller, harness and power seat elevation feature.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio.You asked the Plan to pre-approve Entyvio. You say that the requested Entyvio is medically necessary.The Plandenied your request. The Plan says the enrollee must try and fail Remicade OR Inflectra first.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 Entyvio. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is with Crohn's disease with fistula. At issue in this case is the medical necessity of Entyvio. The provided medical records do not indicate that the enrollee has tried and failed the required drugs first. The provided medical records do not indicate that the Plan's required drugs would 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 Entyvio have not been met.Therefore, we decided that the Plan does not have to pre-approve Entyvio.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the OON services. You say that the requested provided did surgery on your left hip.The Plan denied your request. The Plan says the requested service is available in-network.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 OON services.Therefore, we decided that the Plan does not have to pre-approve orthopedic services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gym membership reimbursement for April 29, 2019 to December 2, 2019.
You asked the Plan to pay for gym membership. You say that you had called and spoke to a plan representative when you started the gym and was told the plan would cover $400 a year. The Plan denied your request. The Plan says this is not covered under the plan benefits. You did not purchase the optional supplemental rider. The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits. The services at issue in this appeal are gym benefits. Therefore, we decided that the Plan does not have to pay for the gym membership reimbursement for April 29, 2019 to December 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fold flat, high-back with headrest.
You asked the Plan to pre-approve fold flat, high back with headrest. You say that you need the fold flat, high back with headrest. The Plan denied your request. The Plan says the fold flat, high back with headrest is not medically necessary because the power wheelchair does not have tilt or recline.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of fold flat, high back with headrest have not been met. Therefore, we decided that the Plan does not have to pre-approve a fold flat, high back with headrest.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950).
You asked the Plan to pre-approve the dental service. You say that core build up is medically necessary. You
say that you have a skin condition, Epidermolysis Bullosa (EB), that effects your gums which are very
sensitive. The Plan denied your request. The Plan says core build up is not 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, the requested core build up is not
among those covered under this benefit. The Evidence of Coverage clearly states that core build up is not a
covered service. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on October 22, 2019.
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the documentation does not include the
time spent providing this service on October 22, 2019.
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 99291 is critical care, evaluation and management of the
critically ill or critically injured patient; first 30-74 minutes.
We find that CPT code 99291 is not supported in the record. Specifically, the documentation submitted does
not include the time spend rendering this service. Additionally, the critical care note included is not for the date
of service at issue. Based on this information, we decided that Medicare rules for coverage of the critical care
services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services
(99291) provided on October 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on February 11,
2020.
You asked the Plan to waive the copayment for the eye exam. You say that you have never paid a copayment
for this service before. The Plan denied your request. The Plan says the copayment applied correctly.
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 $45
copayment for Medicare-covered eye exams, including diagnosis and treatment for diseases and conditions of
the eye.
You have been asked to pay a $45 copayment for the eye exam. The eye exam falls within the "Vision care"
benefit category. The records show that a medical eye exam was performed. 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 eye exam provided on February 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee would not get the same level of care at a SNF or at home.The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the present acute care facility.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH), having been admitted with abdominal pain. He was found to have a perforated sigmoid colon in the setting of previously undiagnosed, metastatic, sigmoid cancer. The enrollee underwent surgery to repair the perforation and debulk the tumor. His long-term prognosis is noted to be poor. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional Privigen infusions (J1459).
You asked the Plan to pre-approve additional Privigen infusions. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that acute exacerbations of myasthenia gravis with severe muscle weakness are occasionally treated for an episode of care with a short course of IVIG (2gm/kg divided given up to 5 days) when other treatment modalities are not successful or available with effects lasting up to 8 weeks. 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 additional Privigen infusions. Our reviewer says that the services are not medically necessary. Our physician reviewer found the documentation provided does not support the medical necessity of additional maintenance treatment with Privigen (IVIG). Additionally, the documentation does not support that the Privigen has been effective for you. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional Privigen infusions have not been met. Therefore, we decided that the Plan does not have to pre-approve additional Privigen infusions (J1459).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea stair glide.You asked the Plan to pre-approvea stair glide. You say that you have fallen down the stairs a few timesand your doctor recommended a stair lift.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 stair lifts are not covered because they are not primarily medical in nature. While a stair lift 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 stair glide.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Ambulance Transport (A0429) provided
November 18, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that the copayment should be
waived. The Plan denied your request. The Plan says the correct copayment 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 $250
copayment for Ambulance Services.
You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls
within the Ambulance 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
an Ambulance Transport (A0429) provided November 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits, mammography and lab services (99214, 77063, 77067, 81003, 51798) provided on June 4, 2019 to October 2, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the out-of-network services. You say that the services should be covered. The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were network providers available.
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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visits, mammography and lab services (99214, 77063, 77067, 81003, 51798) provided on June 4, 2019 to October 2, 2019 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided October 4, 2019.
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says Original Medicare is liable for the services at issue.
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 an office visit (99214) provided October 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special features for a prosthetic leg (L5629, L5632).
You asked the Plan to pre-approve the special features. You say that the items are medically necessary. The
Plan denied your request. The Plan says coverage criteria has 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 the special features. Our reviewer says
that the requested items are not considered medically reasonable and necessary in this case. Our physician
reviewer found The enrollee does not have a Symes amputation so the Symes type socket (L5632) is not
medically necessary. The specialty socket (L5629) is not a covered benefit under Medicare rules.
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 special features have not been met. Therefore, we decided that the Plan does
not have to pre-approve special features for a prosthetic leg (L5629, L5632).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on December 5, 2019.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the
documentation did not include a valid physician order or medical records.
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 G0483 is definitive drug testing of 22 or more drug
classes. We looked at the file and the rules. We find that CPT code G0483 is not supported in the medical
record. There were insufficient records that show the tests were needed to identify specific substances that were
inadequately detected by a presumptive drug test. There is no evidence that shows the test was individualized
to identify 22 or more specific non-prescribed medications or illicit substances. The records provided do not
document concerns based on clinical review and judgement. Based on this information, we decided that
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for
the definitive drug testing provided on December 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for repairs made to a wheelchair (K0739, E2379) on November 7, 2019.
You asked the Plan to waive the coinsurance for the repairs. You say that the coinsurance should be waived because the chair should be under warranty. The Plan denied your request. The Plan says records show the warranty was no longer applicable and the correct cost-sharing 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 20% coinsurance for Durable Medical Equipment and related services. You have been asked to pay a 20% coinsurance for the repairs. The repairs fall within the Durable Medical Equipment and related 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 coinsurance for repairs made to a wheelchair (K0739, E2379) on November 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone grafting (placement of bone following dental extraction) for the enrollee.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 under Medicare, the request is not a covered benefit.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approve bone grafting (placement of bone following dental extraction) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the HPV vaccine you received on October 28, 2019.
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this is not covered
under your Part B plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The
Plan follows the same rules.
The records do not show that you have been injured or directly exposed to any illness related to the HPV
vaccine. Therefore, we decided that the Plan does not have to pay for the HPV vaccine you received on
October 28, 2019.
Benefits for the vaccine 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.You asked the Plan to pre-approve continued SNF care. You say that the request for continuation of SNF care is medically necessary.The Plan denied your request. The Plan says the request for continuation of SNF care does not meet criteria.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member is receiving SNF level care and has a history of chronic pressure ulcers. The member continues to receive wound care. The member requires oversight of his medical conditions and medication management. The member requires physical therapy for progression of his mobility at a community level and to establish a maintenance home exercise program. An occupational therapy evaluation is indicated to assess the need for any adaptive equipment. There are skilled needs, but they do not need to be provided on a daily basis. The member's wheelchair mobility is greater than household distances and he is performing essential activities of daily living including bed mobility and transfers without hands on assistance. The member's condition would not be expected to deteriorate with services provided on a less than daily basis. The member's care can be appropriately provided through home-based and outpatient services with intermittent skilled services on a less than daily basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.