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

We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis provided on April 9,
2021.

You asked the Plan to pay for the shoulder elbow wrist hand orthosis. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the item rendered is not supported by the
documentation.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.

The record does not contain valid relevant medical records which support medical necessity for the supplies
provided in this case. Review of the file shows that the documentation submitted did not sufficiently support
the billed supply code or indicate that the provider discussed the need for the billed supply code. The record
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore,
we decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis provided on April 9,
2021.
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 the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet
criteria.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

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 does not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a
reasonable expectation that the enrollee will be able to fully participate in and benefit from the 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on June 3, 2021.

You asked the Plan to pay for outpatient hospital services. 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 member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

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 outpatient hospital services provided on June 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair with power options and
accessories.
You asked the Plan to pre-approve Group 2 power wheelchair. You say that the enrollee requires this new
power wheelchair for pressure relief, comfort, and pain relief. The Plan denied your request. The Plan says the
denial of authorization for this device is correct, because there are concerns about the enrollee's ability to use a
power wheelchair in the home.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Group 2 power wheelchair. Our
reviewer says that the enrollee does not meet the Medicare criteria for the requested Group 2 power wheelchair.
Our physician reviewer found the documentation indicates that the enrollee has a mobility deficit that impairs
mobility-related activities of daily living (MRADLs) in the home and is not ameliorated by a walker, cane, or
manual wheelchair due to pain, weakness, fatigue, and lack of coordination. However, the documentation is not
clear that the enrollee has the appropriate visual function to operate the requested wheelchair safely at this time.
The enrollee is noted to have diplopia and physical therapy evaluation notes that she sees visual disturbances
and has difficulty seeing in low light. Therefore, the requested wheelchair is not 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 Group 2 power wheelchair have not been met. Therefore, we decided that the
Plan does not have to pre-approve a Group 2 power wheelchair with power options and accessories.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durvalumab.
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. 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has stage IIIB non-small
cell lung cancer. Durvalumab is Food and Drug Administration (FDA)-approved for the treatment of
unresectable stage 3 non-small cell lung cancer in adults whose disease has not progressed following
concurrent platinum-based chemotherapy and radiation therapy. As this enrollee has not yet completed
chemotherapy and radiation it is too soon to tell if durvalumab is indicated. The service is not reasonable or
medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Durvalumab.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Vimpat for the enrollee.  You asked the Plan to pre-approve this drug. You say that this is medically necessary. 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 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 Vimpat 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: 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 transfer to an IRF is medically necessary for this
enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The
enrollee's ongoing skilled therapy and nursing needs can be provided in a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for
an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee
will be able to fully participate in and benefit from the 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation services
(A0429, A0425) provided on September 2, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that this claim should be
paid in full because your family could not take you to the hospital because they wanted to avoid the possibility
of contracting COVID-19. The Plan denied your request. The Plan says this claim was covered as medically
necessary care and was processed in accordance with your contract. You are responsible for a $290 copayment
for ambulance services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $290
copayment for ambulance services.
You have been asked to pay a $290 copayment for the ambulance transportation. This means that you have
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for the ambulance transportation services (A0429, A0425) provided on September 2,
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 requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.
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 short-term acute care hospital can provide all the enrollee's present inpatient care
needs and the health plan has stated that continued care in the short-term acute care hospital will be covered.
Continued care in the short-term acute care hospital is appropriate until the enrollee is stable to transfer to a
lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled
nursing facility.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.
You asked the Plan to pre-approve these services. You say that the services are not medically necessary. The
Plan denied your request. The Plan says [Enter plan denial rationale, e.g. "...rules for SNF care have 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the requested Intracept procedure is
considered experimental in nature, as more research is needed to support efficacy. The services are 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 an Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a second pair of eyeglasses provided on
June 22, 2021.

You asked the Plan to reimburse you for a second pair of eyeglasses. The Plan denied your request. The Plan says you cannot reserve the benefit for the first surgery and purchase two eyeglasses after the second surgery.

Medicare covers one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery with insertion of an intraocular lens implant.

The Plan contract says the Plan covers one pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of an intraocular lens. (If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery).

We looked at the file, the Medicare rules and the Plan's rules. The file shows that Medicare and the Plan covers one pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of an intraocular lens. (If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery). Therefore, we decided that the Plan does not have to reimburse you for a second pair of eyeglasses provided on June 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Timolol maleate solution.
You asked the Plan to pre-approve Timolol maleate. You say that the requested treatment is a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered
drugs have not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Timolol
maleate solution.
Benefits for Timolol maleate 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Xiidra drops.
You asked the Plan to pre-approve Xiidra. You say that the requested treatment is a medical necessity for the
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not
been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Xiidra drops.
Benefits for Xiidra 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xolair for the enrollee.
You asked the Plan to pre-approve Xolair. You say that this is medically necessary for the enrollee. The Plan
denied your request. The Plan says that this drug is supported if the member still has asthma problems even
with the member's current drug treatments.
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 Xolair. Our reviewer says that Xolair is
not medically reasonable and necessary. The requested use of Xolair is not FDA-approved for the enrollee's
diagnosis. The use of Xolair is not supported by one of the major drug compendia or by clinical research that
appears in a Centers for Medicare & Medicaid Services approved medical journal for the enrollee's condition.
Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Xolair.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Xolair have not been met. Therefore, we decided that the Plan does not have to
pre-approve Xolair for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom fabricated abutments (D6057 x4), and an
implant/abutment supported fixed denture for edentulous arch (D6115).
You asked the Plan to pre-approve custom fabricated abutments, and an implant/abutment supported fixed
denture for edentulous arch. You say that the services are medically necessary. The Plan denied your request.
The Plan says the services at issue are not covered benefits.
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-approve
custom fabricated abutments (D6057 x4), and an implant/abutment supported fixed denture for edentulous arch
(D6115).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Keytruda (J9271).
You asked the Plan to pre-approve Keytruda. 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.
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 Keytruda. Our reviewer says that the
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the
requested use of Keytruda is not FDA-approved for the enrollee's diagnosis. Furthermore, the is not use
supported by one of the major drug compendia or by clinical research that appears in a Medicare-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 Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve treatment with Keytruda (J9271).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS system (33289, C2624).
You asked the Plan to pre-approve a CardioMEMS system. You say that the requested item 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 item 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 a CardioMEMS system. Our reviewer
says that the requested item is not considered medically reasonable and necessary in this case. Our physician
reviewer found that there remains a dearth of randomized, blinded clinical studies examining long-term clinical
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the
CardioMEMS system would not be considered medically appropriate and necessary in the enrollee's clinical
management.
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 CardioMEMS system have not been met. Therefore, we decided that the Plan
does not have to pre-approve a CardioMEMS system (33289, C2624).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (R0070) provided on June 28, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not
payable.
The Plan must follow Medicare rules. Medicare rules say that the transportation HCPCS R0070 or R0075 must
be billed in conjunction with the CPT radiology codes.
We looked at the file and Medicare rules. In this case, the transportation code (R0070) was not billed on the
same claim as the radiology codes, and therefore is not payable. 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 for the services (R0070) provided on June 28, 2021.