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

We decided that the Plan has to pre-approve a power scooter (K0806).
You asked the Plan to pre-approve the power scooter. You say that the power scooter is medically necessary.
The Plan denied your request. The Plan says that since the scooter can be used outside the home, it is not
covered.
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility
deficit that impairs their participation in MRADLs, the patient's condition cannot be ameliorated by a walker,
cane or manual wheelchair, and the patient is 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 the power scooter. Our reviewer says
that the power scooter is medically necessary. Our physician reviewer found the patient does have a personal
mobility deficit that impairs activities of daily living. The records show that cane, walker would not be
appropriate due to fall risk and she was reported to not be able to push a wheelchair manually due challenges
with mobility around the home and transfer. The record shows that the enrollee currently uses a power scooter
in the home.
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 power scooter have been met. Therefore, we decided that the Plan has to pre-approve a power scooter
(K0806).
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 pre-approve a replacement prosthesis with an advanced foot and knee.

You asked the Plan to pre-approve the prosthesis. You say that the prosthesis is medically necessary. The Plan denied your request. The Plan says the request for a complete prosthetic replacement with K3 foot and knee does not meet Medicare criteria as reasonable and necessary.

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 prosthesis have not been met. Review of the records show that your current knee and foot are still under warranty. The records show that your health plan has paid for these items. Medicare does not cover replacement of items that are under warranty and that is why these requested items are still denied. Therefore, we decided that the Plan does not have to pre-approve a replacement prosthesis with an advanced foot and knee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the caries risk assessment.
You asked the Plan to pre-approve the caries risk assessment. The Plan denied your request. The Plan says the
service is not a covered 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-approve the
caries risk assessment
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
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 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 you have lumbar spinal stenosis. The requested Superion spacer is considered experimental in nature, as more research is needed to show safety and 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 a Vertiflex Superion spacer.
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 IRF services are medically necessary for this
enrollee to regain maximum function. The Plan denied your request. The Plan says the criteria for admission to
an IRF are not met. The enrollee can safely receive the necessary services in an alternate setting.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment (CPT code E0486), for the enrollee.

You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the enrollee's testing showed they may benefit from positive airway pressure (PAP) to help the enrollee sleep. The Plan states the records do not show that PAP is contraindicated or that the enrollee is not able to tolerate it. The Plan states this service is not 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 DME. Our physician reviewer found based on the medical records provided there is no documentation that meets the requirements listed in the LCD: Oral Appliances for Obstructive Sleep Apnea (L33611) for Medicare coverage of the requested oral device/appliance used to reduce upper airway collapsibility. Records indicate the enrollee has claustrophobia and would prefer the oral device, but records do not document trial and failure of a continuous positive airway pressure device or a medical contraindication to its use.

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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment (CPT code E0486), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory work provided on July 8, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory work. You say that the services are medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on July 8, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the brain (70551) rendered on June 29, 2021.
You asked the Plan to waive the copayment for a magnetic resonance imaging of the brain. You say that you say that you paid $12.18 and was billed $200. You also say that according to what you read, this is backwards. The Plan denied your request. The Plan says you were charged the correct cost sharing amount.
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 $200 copayment for diagnostic radiology other than commuted tomography (CT) scans.
You have been asked to pay a $200 copayment for diagnostic radiology other than commuted tomography (CT) scans for a magnetic resonance imaging of the brain. A magnetic resonance imaging of the brain falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. 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 a magnetic resonance imaging (MRI) of the brain (70551) rendered on June 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the crown (D2740) provided on April 27, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay more for the crown. You say that you do not understand why the Plan only paid $176.25 for this service because you were told differently. The Plan denied your request. The Plan says the treating provider does not have a contract with the Plan as a participating provider and is allowed to bill the difference of the allowed amount and their billed amount to you.  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, you are responsible for a 50% coinsurance of the covered plan allowance after the $100 annual deductible is met for crowns. You are also responsible for the difference between the billed amount and allowed amount for covered dental services received OON. Therefore, we decided that the Plan does not have to pay more for the crown (D2740) provided on April 27, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom fabricated oral appliance (E0486) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the oral appliance. You say that the servicing provider is out of network and you would like it to be considered at the in network benefit level. The E0486 is a custom fabricated device. This is for Medical not dental. You are also a Medicare preferred provider. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 custom fabricated oral appliance (E0486) to be provided by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on June 22, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that the ER doctors misdiagnosed you, so you should not have to pay this copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that you are not being assessed cost sharing for the computed tomography scan.
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 $90 copayment per visit for emergency room services. You have been asked to pay a $90 copayment per visit for the ER visit. This copayment applies regardless of your satisfaction with the services received. 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 emergency room (ER) visit you had on June 22, 2021
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Retacrit.

You asked the Plan to pre-approve Retacrit. You say that the enrollee has chronic kidney disease and anemia.
The Plan denied your request. The Plan says that there is no documentation of ferritin or transferrin values.

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 Retacrit. Our physician reviewer found
that in this case, the record indicates the enrollee has a diagnosis of anemia of chronic renal disease, not on
dialysis. The record also indicates that the enrollee has a hemoglobin of 11.2. The FDA has stated the requested
drug is indicated for the treatment of anemia due to chronic kidney disease, including those on dialysis and not
on dialysis to decrease the need for red blood cell transfusion. The documentation does support that the
requested drug is safe and effective and otherwise reasonable and necessary for this enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Retacrit have been met. Therefore, we decided that the Plan has to pre-approve
Retacrit.

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 pre-approve extra heavy duty, extra wide hospital bed, with weight capacity greater than 600 pounds (E0304).
You asked the Plan to pre-approve the hospital bed. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says under Medicare guidelines, your request is not medically necessary because the records do not show that the enrollee does not weigh at least 600 pounds.
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary when at least one of the following criteria is met: 1. The patient has a medical conditions which requires positioning of the body in ways not feasible with an ordinary bed; or
2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain; or 3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out; or 4. The patient requires traction equipment, which can only be attached to a hospital bed. We looked at this physician's review, the file, and Medicare rules. In this case, an extra heavy duty, extra wide hospital bed with a weight capacity greater than 600 pounds is being requested. The records do not show that the enrollee weighs more than 600 pounds. The records show that you weigh 363 pounds. Based on this information, we decided that Medicare rules for coverage of the hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve extra heavy duty, extra wide hospital bed, with weight capacity greater than 600 pounds (E0304).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent nursing facility care provided on July 12, 2021, to August 23, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the subsequent nursing facility care. You say that the service was provided with no adequate time frame to obtain authorization for the service. You say the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on July 12, 2021, to August 23, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an echocardiography, transthoracic, real-
time with image documentation (93306) rendered on July 6, 2021.
You asked the Plan to waive the copayment for an echocardiography, transthoracic, real-time with image
documentation. You say that you were not aware that the copayment would be this high. You also say that you
have had the same procedure done multiple times at the same location and you recall paying little to nothing.
You also say there is a conflict between the Plan documents and Medicare documents. The Plan denied your
request. The Plan says you were charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The Plan contract says that there is a $1,250 deductible for all items
and services except those specifically excluded by the Plan contract.
You have been asked to pay a $425.15 deductible for an echocardiography, transthoracic, real-time with image
documentation. An echocardiography, transthoracic, real-time with image documentation falls within the
outpatient diagnostic tests and therapeutic services and supplies benefit category. The Plan has followed
Medicare rules by clearly disclosing in the contract that there is a $1,250 deductible, which applies to an
echocardiography, transthoracic, real-time with image documentation. 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 that
had not been met at the time of the echocardiography, transthoracic, real-time with image documentation
rendered on July 6, 2021. Therefore, we decided that the Plan does not have to waive the copayment for an
echocardiography, transthoracic, real-time with image documentation (93306) rendered on July 6, 2021
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the breast biopsy provided on June 25, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the breast biopsy. You say that the service was medically necessary. The Plan denied your request. The Plan says although the claim originally denied for not meeting Medicare criteria, there was no prior authorization obtained.  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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the breast biopsy provided on June 25, 2021, by an out-of-network (OON) provider.