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

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.You asked the Plan to pre-approve these services. You say that your life is in danger.The Plan denied your request. The Plan says the admission is not medically necessary.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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you were admitted to the hospital on February 22, 2020 with chest pain. You received oral medications and had stable vital signs. You received physical and occupational therapy in the hospital and need assistance with walking 140 feet with a rolling walker. You need varied levels of assistance with activities of daily living. You have no skilled nursing needs. You have skilled therapy needs but do not require skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of care.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 thatthe Plan does not have to pre-approvea skilled nursing facility (SNF) admission.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to enrollee on August 20, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11.Therefore, we decided that the Plan does not have to pay for the drug testing rendered to enrollee on August 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora CT scan provided on September 23, 2019.You asked the Plan to waive the copayment fora CT scan. You say that you disagree with the charges because you suffered from a bad infection.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 $195 copayment for advanced imaging services. You have been asked to pay the allowed amount of $191.78, which is less than the $195 copayment for a CT scan. A CT scan falls within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amountbased 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 fora CT scan provided on September 23, 2019.We note your complaint that you are unhappy with the service you received. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power seatelevation system.You asked the Plan to pre-approvea power seat elevation system. You say that you need a power seat elevation systemfor pressure relief. The Plan denied your request. The Plan says power seat elevation systems are not covered by Medicare.The Plan follows Medicare rules. Medicare rules say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary.The file shows that . This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approvea power seat elevation system.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane injections for the enrollee.You asked the Plan to pre-approve Durolane. You say that this is medically necessary.The Plan denied your request. The Plan says that the enrollee does not meet step therapy criteria.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 Durolane. Our reviewer says that Durolane is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed Orthovisc and Monovisc (which are also Hyaluronic acid) or that they would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Durolane.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met.Therefore, we decided that the Plan does nothave to pre-approveDurolane injections for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a toric lens to be inserted during your cataract surgery.
You asked the Plan to pre-approve the requested services. You say that you fear you might lose your vision. The Plan denied your request. The Plan says Medicare only pays the amount of the conventional intraocular lens.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL. While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pre-approve a toric lens to be inserted during your cataract surgery.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tacrolimus at a lower cost level.You asked the Plan to pre-approve Tacrolimus at a lower cost level. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this request is not covered for a tier exception because the drug requested is not covered under Medicare Part D.The Plan must follow Medicare rules. The rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary.We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Tacrolimus at a lower cost level have not been met. Specifically, this drug is covered under Medicare Part B which means it is not eligible for a Part D tier exception. Therefore, we decided that the Plan does not have to pre-approve Tacrolimus at a lower cost level.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper denture (D5110).You asked the Plan to pre-approve the dental item. You say that you received your dentures on September 26, 2016. You say that they have never fit properly. You say that you sneezed while wearing them and they flew out. You say the maxillary denture broke beyond repair.The Plan denied your request. The Plan says dentures are 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, dentures are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvean upper denture (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in bathtub.You asked the Plan to pre-approve a walk-in bathtub. You say that the enrollee is oxygen dependent, can no longer use a shower because of the humidity, and cannot climb into a bathtub.The Plan denied your request. The Plan says a walk-in tub is a convenience item and not covered by Medicare or the Plan.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. Medicare does not cover home modifications.Therefore, we decided that the Plan does not have to pre-approvea walk-in bathtub.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Kinova Jaco 2 robotic arm.You asked the Plan to pre-approvea Kinova Jaco 2 robotic arm. You say that because of a medical condition the enrollee is incapable of reaching beyond the armrests of a power wheelchair.The Plan denied your request. The Plan says a Jaco V2 robotic arm is not medical in nature andwould not improve amedical condition.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.A wheelchair mounted assistive robotic arm is considered a personal convenience item and not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approvea Kinova Jaco 2 robotic arm.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removal of lateral exostosis (D7471), two guidedtissue regenerations (D4266 x2), two alveoloplasties in conjunction with extractions (D7311 x2), and twelve extractions (D7210) to be provided by an oral and maxillofacial surgeon.You asked the Plan to pre-approvethe removal of lateral exostosis, guided tissue regenerations, alveoloplasties, and extractions. You say that the enrollee needs multiple extractions and exostosis on non-restorable teeth, and alveoloplasties.The Plan denied your request. The Plan says the removal of lateral exostosis,guided tissue regenerations, and alveoloplasties are not covered services. The Plan also says that there is no referral on file for these procedures to be rendered by an oral and maxillofacial surgeon.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 removal of lateral exostosis, guided tissue regenerations, and alveoloplasties are not among those covered under this benefit. The contract also clearly states that referrals to specialists are required from the enrollee's general dentist. The record shows that you are requesting these services to be provided by an oral and maxillofacial surgeon and no referral is on file.Therefore, we decided that the Plan does not have to pre-approvea removal of lateral exostosis (D7471), two guided tissue regenerations (D4266 x2), two alveoloplasties in conjunction with extractions (D7311 x2), and twelve extractions (D7210) to be provided by an oral and maxillofacial surgeon.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveKeytruda for the enrollee.You asked the Plan to pre-approveKeytruda. The Plan denied your request. The Plan says that there is no support for Keytruda monotherapy in initial treatment of NSCLC in patients without PDL1 gene expression.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 in this case. Keytruda is not FDA-approved for the enrollee's diagnosis. The use of Keytruda is not listed as indicated, supported or recommended in any of the compendia. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for coverage of Keytruda.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-approveKeytrudafor the enrollee.
Appeal type: Surgery
Decision: Favorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A).If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.You asked the Plan to pre-approve a shower chair. You say that you cannot shower while standing up because you had spine surgery and your doctor said it could take two to three months to heal. You say that you are afraid and think that it is dangerous for you to shower without the requested chair. You stated that you do not want to slip in the shower and said that anything that can be provided to help prevent a slip would be helpful.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 thePlan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea shower chair.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve35 additional trips for routine transportation.You asked the Plan to pre-approve additional trips. The Plan denied your request. The Plan says your benefit covers up to 30 trips.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 30 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the requested additional trips will exceed the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approve 35 additional trips for routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant (D6010).
You asked the Plan to pre-approve the endosteal implant. You say that the enrollee wishes to replace missing teeth in order to improve their chewing on the right side of the mouth. You also say that you feel the enrollee will significantly benefit from an implant. The Plan denied your request. The Plan says this service is not covered under the enrollee's 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 surgical placement of implant body: endosteal implant (D6010).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the physician.
You asked the Plan to pre-approve the physician's services. You say that the group has agreed to use the Plan's fee schedule. You say this physician has already done surgery on one of your hips and you do not want to see a different physician. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care 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 physician's services to be provided by the physician.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provideupper extremity prosthesiselectrode pairand Myo-Silicone Socket.You asked the Plan to provideelectrode pair (L7499), and Myo-Silicone Socket (L7499). You say that [Enter appellant's argument from appeal letter, e.g. "...you need SNF care."]The Plan denied your request. The Plan says theelectrode pair and Myo-Silicone Socket cannot be requested separately from the approved terminal device L7007.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, we have confirmed that code electrode pair (L7499)and Myo-Silicone Socket (L7499) havea bundled relationship with code L7007and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to provideupper extremity prosthesiselectrode pair, and Myo-Silicone Socket.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on June 13, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that these services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that these services were referred by a non-participating skilled nursing facility.
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 skilled nursing services provided on June 13, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on February 15, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 95999 is not supported.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 95999 is unlisted neurological or neuromuscular diagnostic procedure.We find that CPT code 95999 is not supported in the medical record. Specifically, the records show that train of four testing was performed and there is a more appropriate code for these services. 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 pay forthe services rendered on February 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on April 3, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 80307 and HCPCS G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on April 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).You asked the Plan to pre-approve the complete mandibular denture. You say that you lost your upper denture. You also say that you have trouble eating.The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.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, complete mandibular dentures (D5120) are limited to one procedure every five plan years. The record shows that you received an upper and lower denture on June 27, 2019 and your denture benefit is now exhausted.Therefore, we decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).