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

We decided that the Plan does not have to pre-approve powered upper extremity range of motion assist device,
elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and
accessories, custom fabricated (L8702), for the enrollee.
You asked the Plan to pre-approve the item. You say that the durable medical equipment is medically
necessary. The Plan denied your request. The Plan says this item is not covered under Medicare or the Health
Plan.
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 item. Our physician reviewer found
the medical records provided do not meet the requirements listed in the LCD/PIM for Medicare coverage for
the powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double
upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated (L8702). At
this time the requested robotic orthosis is not proven to be more beneficial for treatment of the patient's medical
condition/function of hemiparesis after stroke than any available standard therapy. The requested device is not
reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a
malformed body member.
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 item have not been met. Therefore, we decided that the Plan does not have
to pre-approve powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or
double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated
(L8702), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that, in this case, the requested procedure session exceeds the allowed limit of no more than two (2) sessions per region of the spine in a rolling twelve (12) month period. Therefore, the enrollee does not meet the criteria for this request, and it is deemed medically unreasonable and unnecessary at this point. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.
You asked the Plan to pre-approve Prolia. You say that this is medically necessary for the enrollee. The Plan
denied your request. The Plan says that the enrollee has not met 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 Prolia. Our reviewer says that Prolia is
not medically reasonable and necessary for the enrollee in this case. There is no evidence that the enrollee is
allergic to or intolerant of zoledronic acid. There is no evidence that the enrollee has tried and not responded to
zoledronic acid. There is no documentation as to why zoledronic acid would not be expected to be safe and
effective for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy
criteria for Prolia.
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 Prolia for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda, Carboplatin and Paclitaxel for the enrollee.
You asked the Plan to pre-approve these drugs. You say that the enrollee needs to start this treatment. The Plan
denied your request. The Plan says that these drugs are not supported.
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 these drugs. Our reviewer says that
these drugs are not medically reasonable and necessary for the enrollee in this case. These drugs are being
requested for the treatment of newly recurrent triple negative breast cancer involving her liver. The
combination is not FDA approved. The combination requested is not supported in any of the CMS approved
compendia. There are no supporting citations in a PubMed search. The use is not listed as not indicated, not
supported or not recommended in any of the compendia. Our physician reviewer found that the enrollee's
condition does not meet criteria for coverage of these drugs.
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 drugs have not been met. Therefore, we decided that the Plan does not
have to pre-approve Keytruda, Carboplatin and Paclitaxel for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift.
You asked the Plan to pre-approve a stair lift. You say that you would like the Plan to reconsider providing coverage. 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-approve a stair lift.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided to the enrollee
from January 15, 2020 to January 16, 2020.
You asked the Plan to pay for the acute inpatient hospital care. You say that these services were medically
necessary. The Plan denied your request. The Plan says that the enrollee only met observation level of care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this
case. The record showed that at the time of inpatient admission it was not reasonable for the admitting
physician to expect that the enrollee's necessary hospital care (including earlier emergency department and/or
observation care) would span two midnights. Our physician reviewer found that the enrollee's condition did not
meet Medicare criteria for acute inpatient hospital 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 the acute inpatient hospital care have not been met. Therefore, we decided that
the Plan does not have to pay for the acute inpatient hospital care provided to the enrollee from January 15,
2020 to January 16, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for
SNF care. The Plan denied your request. The Plan says the treatment needed can be provided in a lower level
of care. The Plan says that the enrollee is not eligible for SNF coverage because all that is needed is custodial
care.
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 the SNF services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to
safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not
have complex daily wound care or other ongoing skilled nursing needs that require a SNF admission. His
functional level is near baseline and does not require skilled therapy services with the specialized skill,
knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and
reasonable treatment in a SNF. He does not require skilled nursing or skilled therapy services (or a combination
of these services) on a "daily basis" in a SNF. As a practical matter, the enrollee does not require the necessary
services on an inpatient basis, in a skilled nursing facility setting.
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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Auryxia for the enrollee.
You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this is not
covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Auryxia 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular assay provided on January 16, 2020.
You asked the Plan to pay for the testing services. You say that the services were required to treat the enrollee safely and accurately. The Plan denied your request. The Plan says molecular genetic screening testing is not a Medicare benefit without documentation of medical indication.
The Plan must follow Medicare rules. Medicare rules say that providers must produce medical records showing why the lab services provided were medically necessary. We looked at the file and Medicare rules. In this case, there were insufficient records provided to show the results of this testing would be used to determine a specific diagnosis or specific treatment strategy for disease or illness present in the enrollee at the time of service. This testing is not covered for screening purposes. 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 molecular assay provided on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmological services: medical examination and evaluation (92014) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve ophthalmological services to be provided by an OON provider. You say that you would like this provider to perform the services. The Plan denied your request. The Plan says the services are non-emergent in nature. Therefore, coverage criteria has not been met.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve ophthalmological services: medical examination and evaluation (92014) 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 comprehensive orthodontic treatment of the adult dentition (D8090) provided on October 25, 2016 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says the service is not a covered benefit under the 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. This service/dental code is not listed in your EOC as a covered benefit; therefore, it is not covered. Your EOC states, your benefit covers Medicare-covered dental services and $150 maximum allowance for non-Medicare covered preventive dental services, such as oral exams, cleanings and dental x-rays. Therefore, we decided that the Plan does not have to pay for comprehensive orthodontic treatment of the adult dentition (D8090) provided on October 25, 2016 by an out-of-network provider.
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 this should be allowed due to your other
medical conditions. The Plan denied your request. The Plan says a lower level of care 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 is a female who was hospitalized with a hip fracture for which she
underwent cephalomedullary nailing on 6/29/2020 with post-operative course with pain, nausea, and
hyponatremia, which are now resolved. 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.
The patient's medical status does not currently require intensive physician and nursing oversight only in an IRF.
The patient may benefit from multiple therapies such as physical and occupational therapy but the
documentation does not support that she requires this on an intensive rehabilitation therapy program provided
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a duplex scan of extremity veins (93970).
You asked the Plan to pre-approve a duplex scan of extremity veins. 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 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 a duplex scan of extremity veins. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found the request for the repeat study is not elaborated upon by the requesting
physician. The review of the report generated of the June 16, 2020 scan seems complete and the indication for a
repeat exam is not explained by the requesting physician.
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 duplex scan of extremity veins have not been met. Therefore, we decided that
the Plan does not have to pre-approve a duplex scan of extremity veins (93970).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for gingival irrigation - per quadrant (D4921) provided on
December 16, 2019.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says the service is not a covered benefit under the 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. This service is not listed in your EOC as a covered benefit; therefore, it
is not covered. Therefore, we decided that the Plan does not have to pay for gingival irrigation - per quadrant
(D4921) provided on December 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee is receiving appropriate care at the current 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The member is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The clinical assessment does not indicate an expectation that the enrollee is likely to benefit from, and improve with LTACH services. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350), adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures (D0431), unspecified periodontal procedure, by report (D4999), gingival irrigation - per quadrant (D4921) and oral hygiene instructions (D1330) provided on February 14, 2020 and February 27, 2020.
You asked the Plan to pay for the dental services. You say that you thought the Plan would cover up to $1,000 for dental services. The Plan denied your request. The Plan says the services are not a covered benefit under the 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. These services/dental codes are not listed in your EOC as covered benefits; therefore, the services are not covered. Therefore, we decided that the Plan does not have to pay for 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350), adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures (D0431), unspecified periodontal procedure, by report (D4999), gingival irrigation - per quadrant (D4921) and oral hygiene instructions (D1330) provided on February 14, 2020 and February 27, 2020.