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

We decided that the Plan does not have to pay for the TLSO provided on March 16, 2021.
You asked the Plan to pay for Tlso, flexible, off -the-shelf (L0457). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician.
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 Tlso, flexible, off-the-shelf (L0457). Our reviewer says that the available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. 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 an LSO 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 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 Tlso, flexible, off-the-shelf (L0457) have not been met. Therefore, we decided that the Plan does not have to pay for the TLSO provided on March 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the thoracic lumbar sacral orthosis (TLSO) provided on March 29, 2021.
You asked the Plan to pay for Tlso, flexible, off-the-shelf (L0457). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician.
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 Tlso, flexible, off-the-shelf (L0457).
Our reviewer says that the available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. 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 an LSO 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 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 Tlso, flexible, off-the-shelf (L0457) have not been met. Therefore, we decided that the Plan does not have to pay for the thoracic lumbar sacral orthosis (TLSO) provided on March 29, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are 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 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care.
You asked the Plan to pre-approve inpatient mental health care. You say that the enrollee with schizoaffective disorder has reports of ongoing auditory hallucinations. You state the enrollee is not ready for discharge as evidenced by continued hearing voices giving orders. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 inpatient mental health care. Our
physician reviewer found this enrollee does not meet the criteria for treatment in an acute inpatient mental
health treatment beyond the date in question of August 8, 2021, forward and could have been treated in a lesser
restrictive setting as the enrollee was not showing any suicidal or homicidal ideation, auditory or visual
hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant
while not showing any acute threats to safety.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the
Plan does not have to pre-approve continuation of inpatient mental health care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services rendered on January 12, 2021 to January 13, 2021.
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 services are not covered when performed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. The file shows that the provider billed procedure codes 99205 (office visit), 99211 (office visit), 97032 (electrical stimulation), 97530 (therapeutic activities), and 99213 (office visit). These services are not covered when performed by a chiropractor. Therefore, we decided that the Plan does not have to pay for the chiropractic services rendered on January 12, 2021 to January 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion of an interbody biomechanical device (22853) and vertebral corpectomies (63081, 63082) provided on October 22, 2020.
You asked the Plan to pay for the insertion of an interbody biomechanical device and vertebral corpectomies. You say that these procedures are documented. The Plan denied your request. The Plan says these codes are 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. 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 insertion of an interbody biomechanical device and vertebral corpectomies. Our reviewer says that these codes are not supported.
Our physician reviewer found the medical records provided do not include sufficient documentation to validate that a vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment was performed on October 22, 2020; therefore, code 63081 cannot be verified. As codes 22853 and 63082 are add-on codes, they are not supported without the primary procedure of 63081. 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 insertion of an interbody biomechanical device and vertebral corpectomies have not been met. Therefore, we decided that the Plan does not have to pay for the insertion of an interbody biomechanical device (22853) and vertebral corpectomies (63081, 63082) provided on October 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuous passive motion exercise device for use on knee only (E0935).

You asked the Plan to pre-approve the continuous passive motion exercise device. You say that you believe that based on the fact that the enrollee had a knee replacement and developed arthrofibrosis, that the CPM was medically necessary to assist in her post-operative recovery and to ensure an excellent outcome. The Plan denied your request. The Plan says since this CPM device was started more than three months after the knee replacement surgery, Medicare does not provide coverage for this item.

The Plan must follow Medicare rules. The rules say that coverage for CPM devices is limited to the three-week period following total knee replacement surgery during which the device is used in the home. 

Records show that knee replacement surgery was received on February 23, 2021. The file shows that a CPM device was used for three weeks following this surgery. Therefore, we decided that the Plan does not have to pre-approve the continuous passive motion exercise device for use on knee only (E0935).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Monovisc.
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 step therapy requirement is not met.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found you have a diagnosis of left knee osteoarthritis. You have not tried and failed the Plan's required drugs, Gel One and Synvisc. The records do not support that the required drugs would be less effective or have adverse effects; therefore, the Monovisc 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 Monovisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0848).
You asked the Plan to pre-approve a group 3 power wheelchair (K0848). You say that the requested group 3 power wheelchair (K0848) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested group 3 power wheelchair (K0848).
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 a group 3 power wheelchair (K0848). Our reviewer says that the enrollee does not meet criteria for the requested group 3 power wheelchair (K0848). Our physician reviewer found the enrollee has a personal mobility deficit that impairs participation in MRADLs. The April 2021 physician progress note indicates enrollee has difficulty sequencing, impaired safety awareness, inappropriate judgment, short term memory loss, fatigue, and forgetfulness.
Oriented to person and place. It is unclear why the enrollee's caregiver is unable to propel the enrollee in a manual wheelchair. The physician documentation does not support this enrollee can safely operate a PMD. 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 group 3 power wheelchair (K0848) have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0848).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve standard wheelchair (CPT code K0001RR), for the enrollee.
You asked the Plan to pre-approve the DME. You say that this is medically necessary based on the enrollee's repeated falls. The Plan denied your request. The Plan says the Medicare rules have not been met. 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 DME. Our physician reviewer found the enrollee does not have a mobility limitation that significantly impairs their ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. It is not clear why the enrollee is unable to use an appropriately fitted cane or walker. The documentation does not indicate that the use of a manual wheelchair will significantly improve the patient's ability to participate in MRADLs and the enrollee will use it on a regular basis in the home. The documentation does not reveal that the enrollee has adequate maneuvering space in the home for the requested device. 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve standard wheelchair (CPT code K0001RR), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) and
electrocardiogram (93005) provided on October 20, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the outpatient visit. You say that you were unable to verify the enrollee's plan on
the date of service. These charges should be reviewed for medical necessity as the services were ordered by the
physician. The Plan denied your request. The Plan says enrollee's must receive their medical services from an
in-network provider with the exception being urgent or emergent services. Non-emergent services with noncontracted
providers require prior authorization before 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 had network providers
available who could have provided 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 hospital outpatient clinic visit (G0463) and
electrocardiogram (93005) provided on October 20, 2020 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Denosumab.
You asked the Plan to pre-approve Denosumab. 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 follows Medicare rules. Medicare rules say that upon review, if the drug use is not on the FDA label, does not appear on the American Hospital Formulary Services (AHFS), Elsevier/Gold Standard Clinical Pharmacology, NCCN Drugs and Biologics Compendium, Truven Health Analytics Micromedex DrugDex and/or Wolters Kluwer Lexi-Drugs compendium or National Government Services has not published an LCD or article covering the off-label use as listed below, then the drug use is not approved and the use of the drug may be denied. 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 Denosumab. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the review indicates that the enrollee has prostate cancer with lymph node metastasis and is on androgen deprivation therapy.
He is not is not a candidate for Prolia due to fact that he does not have bone metastasis. There is no other documentation, medicalrecords or literature sources were provided to support the off-label use of Prolia in this enrollee that would satisfy current Medicare Local Coverage Determination (LCD) Drugsand Biologicals, Coverage of, for Label and Off-Label Uses (L33394), last revised 11/7/2019, off-label use of a U.S. Food and Drug Administration (FDA) approved drug for the treatment of a specific condition, other than the condition(s) for which the drug was approved by the FDA. The enrollee does not meet the coverage criteria detailed in the LCD. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Denosumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Denosumab.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702).
You asked the Plan to pre-approve the orthotic device. You say that given that all alternative treatment strategies targeted at restoring his native strenth and range of motion have been tried and failed, the enrollee as been referred for myoelectric orthotic restoration. The Plan denied your request. The Plan says this item is considered experimental and investigational. There is insufficient evidence of its effectiveness.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the cataract surgery (66984) provided on March 1, 2021 and March 15, 2021.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.
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 for Medicare-covered surgery or other services provided to you at an ambulatory surgical center or outpatient hospital, but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay $650 ($325 copayment x 2) for the cataract surgeries provided. 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 copayments for the cataract surgery (66984) provided on March 1, 2021 and
March 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from February 25, 2021, to February 28, 2021.
You asked the Plan to waive the copayment for the inpatient care. You say that you were frustrated by the care provided in an overcrowded hospital and feel you should not be responsible for your copayment. The Plan denied your request. The Plan says the copayment was applied correctly to the inpatient care provided.
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 for each of the first six days of an inpatient admission. You have been asked to pay a $975 copayment for the three-day inpatient admission ($325 x 3 days = $975). 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 hospital admission and services provided from February 25, 2021, to February 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and intraoral x-rays provided on April 8, 2021.

You asked the Plan to pay for the comprehensive oral evaluation and intraoral x-rays. You say that you did not use these benefits prior to this date and both services are fully covered within your plan. You say that the error should be corrected. The Plan denied your request. The Plan says the comprehensive oral evaluation is only covered once every three plan years and intraoral x-rays are 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, a comprehensive oral evaluation is only covered once every three plan years. The plan paid for a comprehensive oral evaluation provided on May 14, 2019, which exhausted your benefit. Intraoral x-rays are not a covered benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and intraoral x-rays provided on April 8, 2021.