Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you feel that you require IRF care to meet your needs. The Plan denied your request. The Plan says there are no acute medical conditions requiring hospital care. Daily skilled services in a skilled nursing facility would be sufficient.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was admitted to the hospital on 2/23 due to abdominal discomfort, found to have heart failure and NSTEMI. He underwent catheterization procedures and had cardiac medication adjustments. He was found to have elevation in creatinine and hypotension on 2/27/20 and his Lasix and Aldactone were held. He was diuresed on 3/1/20 and Aldactone to be considered once creatinine improves. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF. The documentation reveals the patient still has ongoing acute care medical issues such as hyperkalemia, pending chest x-ray results from 3/2/20 and response to recent medication adjustments. The patient may benefit and participate in additional therapy of PT and OT but the patient does not appear to be able to tolerate this therapy require this on an intensive rehabilitation facility therapy program level in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper partial denture (D5213) lower partial denture (D5214).
You asked the Plan to pre-approve the dental services. You say that you were referred to have 2 teeth removed so the partials needs to be adjusted and you don't think that's your fault. You are requesting reconsideration so you can get the work done. 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. The requested service is covered once every 5 years. This service was already provided on January 23, 2017, therefore, this benefit has been exhausted. 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 upper partial denture (D5213) lower partial denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar sacral orthosis provided on January 16, 2019.You asked the Plan to pay forthe lumbar sacral orthosis (L0650). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says rules for telehealth services were not met.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forthe lumbar sacral orthosis provided on January 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approve foot orthotics. You say that because of medical conditions the enrollee suffers from extreme pain making it impossible to complete everyday activities.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for their condition.Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous passive motion exercise device (E0935) and a cold therapy unit.
You asked the Plan to pre-approve a continuous passive motion exercise device and a cold therapy unit. You say that the items are 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 continuous passive motion devices are devices covered for enrollees who have received a total knee replacement. 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 continuous passive motion exercise device and a cold therapy unit. Our reviewer says that the items are not medically necessary. Our physician reviewer found a fluid circulating cold pad with pump is considered not reasonable and medically needed. Continuous passive motion devices are devices covered for enrollees who have received a total knee replacement. The documentation does not indicate the enrollee has received a total knee replacement. A fluid circulating cold pad is not medically necessary per Social Security Act, Section 1862(a)1(A) as this appears to exceed the enrollee's medical need. The enrollee has not had a total knee replacement at this time. There is no evidence that this device would be more beneficial than application of a cold pack post-surgery. 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 continuous passive motion exercise device and a cold therapy unit have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous passive motion exercise device (E0935) and a cold therapy unit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. Atleast four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repair of the upholstered portion of a seat lift chair.
You asked the Plan to pre-approve repair of the upholstered portion of a seat lift chair. You say that the chair is uncomfortable, you can feel the motor when you sit, and you do not use the lift function. The Plan denied your request. The Plan says there is no record of an evaluation for approval of the recliner.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met. We looked at the file and Medicare rules. There are no records of approval of a seat lift recliner. Based on this information, we decided that Medicare rules for coverage of a seat lift recliner have not been met. Medicare only covers the seat lift mechanism. You have stated the seat lift mechanism is in working order. Medicare does not cover the upholstered portion of a seat lift chair. Therefore, we decided that the Plan does not have to pre-approve repair of the upholstered portion of a seat lift chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does nothave to pre-approve a second opinion to be provided by a physician at a Cancer Center.You asked the Plan to pre-approve a second opinion to be provided by a physician with a Cancer Center. You say that all of the in-network physiciansare following the same order of care for your diagnosis and you would like coverage for a second opinion from a physician with a Cancer Center. The Plan denied your request. The Plan says you have only seen one in-network oncologist and you can obtaina second opinion with the Plan's primary network of physicians.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 a second opinion to be provided by a physician with a Cancer Center.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zioptan eye drops for the enrollee.You asked the Plan to pre-approve this drug. You say that the enrollee has glaucoma.The Plan denied your request. The Plan says that your request is not a covered benefit under your Medicare Part B plan.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 Zioptan eye drops for the enrollee.Benefits for this drug 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 incontinence supplies.You asked the Plan to pay forincontinence supplies. You say that you received a denial notice for the purchased supplies. You say that your primary care doctor requested the supplies for you.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pay forincontinence supplies
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
The enrollee asked the Plan to pay for the ambulance services. The enrollee said that they were receiving bills for the ambulance services. The enrollee said that whenever they received a bill they would charge it to their credit card. The enrollee stated that they were contacting their credit card company to get a copy of their payments for the ambulance services and that they were not sure why they were being contacted now. The Plan denied the enrollee's request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on January 3, 2017. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foranti-reflective coating upgrade (V2750) purchased August 15, 2019.You asked the Plan to pay forthe lens upgrade. You say that it was your understanding that the first prescription following cataract surgery is covered with no deductible. You paid $441 and it does not seem fair that you receive zero reimbursement.The Plan denied your request. The Plan says items that are listed as excluded are not covered by the plan. The plan confirmed that the enrollee had cataract surgery and has agreed to pay for standard frames and lenses.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when one pair of eyeglasses or contact lenses after each cataract surgery, which includes standard frames and lenses. The member received an anti-reflective coating upgrade, which is listed as excludedin the medical exclusions chart. We looked at the file and the Plan's rules. The plan confirmed that the enrollee had cataract surgery and has agreed to pay forthe cost of standard frames and lenses of $336. The anti-reflective coating upgrade is listed as excluded.Therefore,the enrollee is responsible for the cost of the upgrade in the amount of $105.Therefore, we decided that the Plan does not have to pay foranti-reflective coating upgrade (V2750) purchased August 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for hip orthosis (L18686) hip joint, adjustable flexion, extension, abduction control (L2624) provided September 18, 2019.You asked the Plan to pay for the orthoses. You say that you ask that in light of the attached documentation, the claim is reviewed and the decision to deny reversed.The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services and confirm Medicare coverage has been met.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered.Therefore, we decided that the Plan does not have to pay for hip orthosis (L18686) hip joint, adjustable flexion, extension, abduction control (L2624) provided September 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 21, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the office visit (99205) and electrocardiogram (93000). You say that the member did not present with the correct insurance information. The Plan denied your request. The Plan says these services were not authorized by network or primary care providers.
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 medical services provided on August 21, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not haveto pre-approveBRCA 1 and 2 testing.You asked the Planto pre-approve the testing. You say that this is medically necessary.The Plan denied your request. The Plansaysthis is not covered without a personal history of breast, ovarian, or pancreatic cancer.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal, the testing, is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plandoes not haveto pre-approveBRCA 1 and 2 testing.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Denosumab (Prolia) for the enrollee.
You asked the Plan to pre-approve Prolia. You say that the enrollee has a non-traumatic compression fracture with 25% height loss. The Plan denied your request. The Plan says the enrollee has not been diagnosed with osteoporosis.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Prolia. Our physician reviewer found that the enrollee has a fragility fracture which meets the clinical definition of osteoporosis. However, hypocalcemia is a contraindication to Prolia use. Monitoring of the enrollee's calcium level is recommended and correction of hypocalcemia is required. The provided medical records do not include a calcium level. Therefore, the requested drug is not medically reasonable and 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Denosumab (Prolia) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on July 23, 2019 and billed under codes 80307 and G0483.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 80307 and G0483 remain not supported. The Plan states the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician) stating exactly what tests are to be performed. Furthermore, per the submitted toxicology profile stating, "My custom profile is effective for 1 year as of the date signed; however, I may make changes at any time." The signature date of the Toxicology Profile is July 16, 2018 however, the billed date of service is July 23, 2019. The Plan states the billed codes cannot be verified. The Plan notes that multiple attempts were made to obtain additional information from the provider.
The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order must be signed appropriately. The medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met.
Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on July 23, 2019 and billed under codes 80307 and G0483.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOne Touch Ultra Test Strips (A4253).You asked the Plan to pre-approveOne Touch Ultra Test Strips (A4253). You say that the requested One Touch Ultra Test Strips are medically necessary.The Plan denied your request. The Plan says the requested One Touch Ultra Test Strips are not medically necessary, and the enrollee can transition to a Plan preferred brand.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 One Touch Ultra Test Strips (A4253). Our reviewer says that the requested OneTouch Ultra Test Strips are not medically necessary. Our physician reviewer found the enrollee is with listed diagnosis of type 1 diabetes mellitus (DM), though no fast acting insulin is used and A1C is 7.1. The enrollee takes lantus 18 units daily and trulicity. He has peripheral vascular disease (PVD). He has been using a One Touch Ultra meter for the last few years and wants to continue with this. The enrollee checks 3 times per day. There is no documentation that he has tried another meter or why another meter would not meet his needs. As we are not told why one of the other meters would not work for him, we cannot say that he meets criteria for use of a non-preferred meter and strips. If he tries one or more of the other options and has trouble with it and his BG monitoring needs are not met, then reconsideration should be made.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of One Touch Ultra Test Strips (A4253) have not been met.Therefore, we decided that the Plan does not have to pre-approveOne Touch Ultra Test Strips (A4253).