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

We decided that the Plan has to pre-approve a below the knee prosthetic and related accessories.
You asked the Plan to pre-approve a below the knee prosthetic and related accessories. You say that the
medical records show the appropriateness of the request for the requested items. You say that the enrollee's
current functional capabilities are documented, as well as her expected functional potential. You say that the
enrollee is ready and motivated to proceed. The Plan denied your request. The Plan says that the information
provided does not demonstrate the medical appropriateness of the requested item. The Plan says that there is no
current clinical information documenting the enrollee's current functional capabilities or their expected
functional potential.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.
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 below the knee prosthetic and related
accessories. Our reviewer says that the below the knee prosthetic and related accessories are considered
medically reasonable and necessary in this case. Our physician reviewer found the medical records provided
show documentation that the criteria for coverage have been met for the requested below the knee prosthesis
and related accessories. A notation in the records from May 19, 2021, indicates the enrollee is ready and
motivated to ambulate at a K1 level and is expected to be able to do this.
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 below the knee prosthetic and related accessories have been met. Therefore,
we decided that the Plan has to pre-approve a below the knee prosthetic and related accessories.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction rendered on March 15, 2021.
You asked the Plan to pay for these services. You say that the services should be covered. The Plan denied
your request. The Plan says the services are not covered.
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 an eye refraction as part of a routine eye exam only.
We looked at the file and the Plan's rules. The file shows that you received an eye refraction as part of a
Medicare-covered eye exam for a diagnosis of cataracts and keratitis. The services were not performed as a
routine eye exam. Based on this information, we decided that the Plan's rules for coverage of these services
have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction rendered on
March 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214), a punch biopsy of skin (11104), and a tissue exam by pathologist (88305)  provided on January 4, 2021, by an out of network provider.

You asked the Plan to pay for an office visit, punch biopsy, and tissue exam. You say that the provider told you that they were in-network. Had you known the services at issue were out of network you would have scheduled the services with an in-network provider.The Plan denied your request. The Plan says rules for out of network care have 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 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 an office visit (99214), a punch biopsy of skin (11104), and a tissue exam by pathologist (88305)  provided on January 4, 2021, by an out of network provider.

Your complaint about receiving erroneous or misleading information from your provider about their Plan participation status is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repetitive transcranial magnetic stimulation (rTMS).

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 services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that rTMS is covered when specific criteria are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of recurrent major depressive disorder. He has not been tried and shown to have a clinically significant response to for trials of pharmacologic agents in the current depressive episode. He has not taken pharmacologic agents in the current episode of depression as noted from his record. He started psychotherapy in June of 2021 and there is no documented standardized rating scales quantifying his depressive symptoms. The criteria for coverage are not met and the rTMS is therefore 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 repetitive transcranial magnetic stimulation (rTMS).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.

You asked the Plan to pre-approve Keytruda. You say that this request is medically necessary.The Plan denied your request. The Plan says the enrollee is part of a clinical trial and this service is not covered.

The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services.

In this case, you asked the Plan to pre-approve Keytruda as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials.Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the commode chair provided on February 28, 2020.
You asked the Plan to pay for the commode chair. You say that this is medically necessary and should be paid. The Plan denied your request. The Plan says that after review of the situation, it is found that no separate payment can be allowed for this item since it must be provided under arrangements by the nursing home, and payment is included in the amount paid to the facility.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Items ordered by a network provider are also considered approved by the Plan. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Review of the record shows that this claim was originally denied due to being noncovered. However, a corrected claim was then submitted which was denied for missing durable medical equipment (DME) modifiers. However, the Plan did not make this argument on appeal review. We do not find any obvious error with the modifiers. In its appeal decision, the Plan states that this cannot be covered because payment for the item would be included in the Prospective Payment System (PPS) payment made to the skilled nursing facility (SNF). Review of the SNF claim, however, reveals that the enrollee was discharged from the SNF on February 28, 2020, which is the date of service for this item. The discharge code shows that the enrollee was discharged for home/self-care. Since the enrollee was no longer an inpatient at the SNF on the date of service, the charge is not included in the SNF PPS payment. The commode chair was ordered by a contract provider, the enrollee's assigned PCP. There is no indication that notice of noncoverage was provided. As such, the item is considered approved by the Plan. Since there is no reason that separate payment cannot be made for the commode, and there is no other valid denial rationale for this approved item, we find that the denial of payment is not supported. Therefore, we decided that the Plan has to pay for the commode chair provided on February 28, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service (CPT code K0553) provided to the enrollee on February 5, 2021.

You asked the Plan to pay for the diabetic supplies. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the diabetic supplies have not been met. The supplier did not include a Delivery Ticket, itemized invoice, or packing slip to indicate the specific supplies; therefore the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service (CPT code K0553) provided to the enrollee on February 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will not be able to function
without LTACH care. The Plan denied your request. The Plan says the enrollee could be treated in another
setting.
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 enrollee is receiving appropriate care at the present acute care hospital. The
enrollee does not require services at the LTACH that are not available at the acute care hospital where she is
currently receiving 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 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.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve JAK2 genetic testing.

You asked the Plan to pre-approve the JAK2 genetic testing. You say that the requested test is medically necessary to rule out other causes of the elevated labs. You say that the medical records support the need for the test.The Plan denied your request. The Plan says that there is no documentation that BCR-ABL testing has been performed. The Plan says that the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

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 JAK2 genetic testing. Our reviewer says that the JAK2 genetic testing is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has leukocytosis, monocytosis, and neutrophilia. The medical history is notable for lung cancer. On June 24, 2021, the plan was to check CBC, CMP, LDH, peripheral smear, flow cytometry, ANA screen, SPEP, kappa lambda ratios, immunofixation of serum and urine, JAK2 mutation with reflex to exon 12, 19, CSF 3 ER, exon 12, and abdominal sonogram. The documentation supports that JAK2 genetic testing is medically reasonable and necessary for the enrollee in this case, to evaluate for the etiology of the enrollee's leukocytosis with neutrophilia. 

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 JAK2 genetic testing have been met.Therefore, we decided that the Plan has to pre-approve JAK2 genetic testing.

If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Reblozyl (J0896).
You asked the Plan to pre-approve Reblozyl. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Reblozyl. Our reviewer says that that the requested treatment is not medically necessary at this time. Our physician reviewer found that Reblozyl is approved by the Food and Drug Administration (FDA) for the treatment of anemia in adults with beta thalassemia who require regular red blood cell (RBC) transfusions. The enrollee has only received 2 transfusions over the past 2 years. In additions, the enrollee's recent slight decrease in hemoglobin is felt to be from blood loss. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Reblozyl have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Reblozyl (J0896).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT of the neck spine and CT of the head/brain provided on June 17, 2020.
You asked the Plan to pay for the CT of the neck spine and CT of the head/brain. You say that you would like this claim to be reconsidered for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the CT of the neck spine and CT of the head/brain provided on June 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mobile x-ray services rendered on December 6, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes. We looked at the file and Medicare rules. Billed procedure codes Q0092 (portable x-ray equipment set up) and R0070 (transportation of portable x-ray equipment) have a PC/TC indicator of 3 and no separate PC payment. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the mobile x-ray services rendered on December 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided March 3, 2020 to March 23, 2020.

You asked the Plan to pay for the inpatient hospital care. You say that DRG 025 is supported in the records. The Plan denied your request. The Plan says the claim was paid at the appropriate DRG, 026.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. 

In this case, you billed the inpatient services provided with DRG 025. 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 inpatient hospital care. Our reviewer says that the appropriate DRG is 026. Our physician reviewer found the patient's urine culture revealed only 10,000 colonies/ml of enterococcus faecalis. In addition, the urinalysis was without evidence of infection as it was negative for leukocyte esterase, negative for nitrites, and the WBC count was 0-5. There was insufficient objective clinical evidence to validate the diagnosis of a urinary tract infection. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided March 3, 2020 to March 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services to be provided by an out-of-network provider.
You asked the Plan to pre-approve the LTACH services. You say that you are trying to get the enrollee moved closer to family that will be able to assist and support the enrollee to aid in their recovery. The Plan denied your request. The Plan says these services can be provided by an in-network provider.
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 LTACH services to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal maintenance (CPT code D4910).

You asked the Plan to pre-approve the dental services. You say that you have pain on your teeth when you drink hot or cold liquid.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-approve periodontal maintenance (CPT code D4910).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this request is medically necessary for
the enrollee's condition. The Plan denied your request. The Plan says this requested procedure is
experimental/investigational.
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 Vertiflex procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and
efficacy of the device before coverage can be approved.
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Vertiflex procedure.