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

 
We decided that the Plan does not have to pre-approve a Lumin CPAP Cleaner. 
 
You asked the Plan to pre-approve a Lumin CPAP Cleaner. You say that you need this because your immune 
system is compromised. The Plan denied your request. The Plan says that this is not reasonable and necessary 
to maintain the CPAP device and cleanliness. 
 
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. Therefore, we 
decided that the Plan does not have to pre-approve a Lumin CPAP Cleaner.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuous glucose monitor.You asked the Plan to pre-approvethe requested device. You say that you want to check your sugars before and after meals.The Plan denied your request. The Plan says coverage criteria have not been met.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are coveredunder certain medical indications.We looked at the file and Medicare rules. The documentation does not indicatethat you use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 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 pre-approvea continuous glucose monitor
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture and a complete mandibular denture.
You asked the Plan to pre-approve the complete maxillary denture and complete mandibular denture. You say that your current dentures are broken, and have not worked since you first received them. You also say that they do not fit properly. The Plan denied your request. The Plan says these services are allowed one time every 60 months. The Plan also says that you had these services less than 60 months ago.
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 limited to one set every 5 years. The record shows that you received a complete maxillary denture and a complete mandibular denture on September 5, 2017, and your dentures benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture and a complete mandibular denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea walk in bathtub.You asked the Planto pre-approvethe tub. You say that you suffer from severe dry skin, and this will relieve the itching.The Plandenied your request. The Plansaysthis is not a covered benefit as hygienic equipment is excluded from coverage.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.Therefore, we decided that the Plandoes not haveto pre-approvea walk in bathtub.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that LTACH care is medically necessary for the enrollee.The Plan denied your request. The Plan says LTACH admission criteria is not met at this time.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. Our physician reviewer found the patient is currently undergoing treatment at an acute care hospital (ACH) for mycobacterium avium-intracellulare infection (MAI) pneumonia and chronic respiratory failure. The enrollee is not intubated/ventilated.  There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fordental services (D0210, D0150, D2392, D2394) provided September 1, 2020.You asked the Plan to pay forthe dental services. You say that the services should be covered.The Plan denied your request. The Plan says the provider was out-of-network and therefore the services are not covered.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. The plan only covers dental services rendered by in-network providers.Therefore, we decidedthat the Plan does not have to pay fordental services (D0210, D0150, D2392, D2394) provided September 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveVertiflex device.You asked the Plan to pre-approveVertiflex device. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested device is not medically necessary.The Plan must follow Medicare rules. Medicare rulessay 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 Vertiflex device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested device is experimental. More research is needed to show safety and efficacy. Therefore, the enrollee does not meet criteria for the requested 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 Vertiflex device have not been met.Therefore, we decided that the Plan does not have to pre-approveVertiflex device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health aide or certified nursing assistant service(S9122) provided on June 1, 2020.You asked the Plan to pay forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says this service is not payable as it has been billed incorrectly.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 S9122 is not supported in the medical record. Specifically, CPT code S9122 has a status indicator of I and will not be paid by Medicare. This service should be reported with a code that is recognized by Medicare. Based on this information, we decided that Medicare rules for coverage of CPT code S9122 have not been met.Therefore, we decided that the Plan does not have to pay forthe home health aide or certified nursing assistant service (S9122) provided on June 1, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on January 13, 2020.You asked the Plan to pay forthe services. The Plandenied your request. The Plan says medical records were not submitted.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The documentation provided does not contain records from the ordering provider's showing his/her intent that the testing in question be performed. 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 forthe drug testing services provided on January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvewound care to be provided by an out-of-network (OON) provider.You asked the Plan to pre-approvewound care. You say that you would like approval for these services.The Plan denied your request. The Plan says these services can be provided in-network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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-approvewound care 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 pre-approvethe core buildup, including any pins when required (D2950).You asked the Plan to pre-approvethe core buildup, including any pins when required. You say that this service is not medically necessary.The Plan denied your request. The Plan says this service is not a covered benefit under your supplemental 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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvethe core buildup, including any pins when required (D2950).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveVascepa 1 gm capsule.You asked the Plan to pre-approveVascepa. You say that this service is medically necessary for the enrollee's condition.The Plan denied your request. The Plan says drug coverage is limited only to those drugs covered under the enrollee's medical benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not payfor 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-approveVascepa 1 gm capsule.Benefits for Vascepamay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay formolecular genetic screening testing provided to the enrollee on April 13, 2020.You asked the Planto pay forthe testing. You say that this should be paid for.The Plandenied your request. The PlansaysMedicare says screening services with no relation to a medical diagnosis of disease for the health of the patient are not a benefit.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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the testing provided on 4/13/2020 was medically reasonable and necessary for the enrollee in this case.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 testing have not been met.Therefore, we decided that the Plandoes not haveto pay formolecular genetic screening testing provided to the enrollee on April 13, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that IRF care is medically necessary.The Plan denied your request. The Plan says rules for IRF care have not been met.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 IRFcare. 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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Purewick external catheter.
You asked the Plan to pre-approve the requested item. You say that without the supplies, you cannot urinate on
your own. The Plan denied your request. The Plan says non-reusable, disposable catheters are not a covered
benefit.
The Plan must follow Medicare rules. Medicare rules say that non-reusable supplies are non-covered.
We looked at the file and Medicare rules. The requested item is a single-use device. 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 pre-approve a Purewick external catheter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you need IRF care.The Plan denied your request. The Plan says rules for IRF care have not been met.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 you do not require the intensity of services provided at an IRF. Specifically, you do not show a requirement of fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea total electric hospital bed.You asked the Planto pre-approvethe bed. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plandoes not haveto pre-approvea total electric hospital bed.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveproton beam radiation therapy.You asked the Plan to pre-approvethe requested services. You say that proton beam therapy has a lower toxicity than conventional radiation therapy.The Plan denied your request. The Plan says there is no research showing the enrollee's cancer responds better to proton therapy.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 requested services. Ourphysician reviewer found that there is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a possible advantage of this expensive therapy. Proton therapy would exceed the needs for this enrollee. Therefore, the requested services are not medically reasonable or 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 the requested services have not been met.Therefore, we decided that the Plan does not haveto pre-approveproton beam radiation therapy
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveoptiwaverefractive analysis system vision testing during cataract surgery.You asked the Plan to pre-approvethese services. You say that you have diabetic damage in your eyes and the only way to see how much or how severe is through the ORA system.The Plan denied your request. The Plan says that they only cover routine vision testing during Cataract surgery.The Plan must follow Medicare rules. The rules say that refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.The services you asked the Plan to pay for is a refractive procedure.Therefore, we decided that the Plan does not have to pre-approveoptiwave refractive analysis system vision testing during cataract surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvebone replacement graft -first site in quadrant (D4263).You asked the Plan to pre-approvethe dental services. You say that you are in pain and cannot chew your food without causing further injury to your mouth.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 handbook as a covered benefit; therefore, it is not covered.Therefore, we decided that the Plan does not have to pre-approvebone replacement graft -first site in quadrant (D4263)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on October 26, 2020.You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.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 Plandid not pre-approve the domiciliary, rest home visit.We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a domiciliary, rest home visit provided on October 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda Solution 100MG/4ML (CPT Code J9271). 
 
You asked the Plan to pre-approve the medication. You say that the member has bladder cancer now and 
previously had prostate cancer. The Plan denied your request. The Plan says the clinical value and effectiveness 
of Keytruda in the setting of low grade, Ta, non-invasive papillary urothelial cancer have not been 
demonstrated in the peer-reviewed literature. 
 
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 the medication. Our physician reviewer 
found the requested use of Keytruda Solution 100MG/4ML (CPT Code J9271) is not FDA-approved for the 
enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that 
appears in a CMS-approved medical journal. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda Solution 100MG/4ML (CPT Code J9271).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron 4mg tablets.
You asked the Plan to pre-approve Ondansetron. You say that Ondansetron is medically necessary. The Plan denied your request. The Plan says Ondansetron is not eligible for coverage under the Part B Medical Benefit for this condition.
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 Ondansetron 4mg tablets.