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

We decided that the Plan has to pre-approve an electronic connection device (E2310) for a power wheelchair.
You asked the Plan to pre-approve electronic connection device. You say that you are paralyzed from the chest down and cannot go to the bathroom without your catheter, walk, stand, or move your legs at all. The Plan denied your request. The Plan says that the denial of authorization for this component is correct, because if the sole function of an electronic connection device is for a power seat elevation or power standing feature, it will be denied as non-covered.
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 electronic connection device. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the function of this electronic connection device is for the operation of the approved power tilt feature, and not for a power seat elevation or power standing feature. Based on the medical records provided this meets Medicare criteria as medically reasonable and 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 electronic connection device have been met. Therefore, we decided that the Plan has to pre-approve an electronic connection device (E2310) for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown (D2740) for tooth # 8.
You asked the Plan to pre-approve the dental service. You say that you are experiencing pain with the same tooth. You say that you feel it is the provider's responsibility to replace the crown. You say that the provider put the crown on a bad tooth in the first place. The Plan denied your request. The Plan says crowns are covered once per tooth every 5 plan years. The Plan also says that the frequency limit has been reached.
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 and the crown is listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for a crown for tooth # 8 that you received on September 23, 2020. Therefore, we decided that the Plan does not have to pre-approve a porcelain crown (D2740) for tooth # 8.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the deductible for the x-ray provided on May 3, 2021.
You asked the Plan to reduce the deductible for the x-ray. You say that you should have a $15 copayment for in-network x-rays. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,000 deductible which applies to each in-network Medicare-covered standard x-ray.
The x-ray you asked the Plan to reduce the deductible for 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 $1,000 deductible which applies to each in-network Medicare-covered standard x-ray. This cost sharing is a contractual obligation that had not been met at the time the x-ray was received on May 3, 2021. Therefore, we decided that the Plan does not have to reduce the deductible for the x-ray provided on May 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care (99222) provided on May 30, 2021.
You asked the Plan to pay for the initial hospital care. You say that you would like reconsideration because the member was seen by multiple physicians with different specialties on the same date. The Plan denied your request. The Plan says another evaluation and management code was billed for the same date of service by another provider in the same group with the same specialty.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that if more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported. In this case, the CPT Code Manual definition of code 99222 is initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit. We find that CPT code 99222 is not supported in the record. Specifically, the record shows that another evaluation and management service was paid on the same date of service for a provider in the same group with the same specialty. The documentation submitted does not show that the services rendered were for unrelated conditions. Based on this information, we decided that Medicare rules for coverage of the initial hospital care have not been met. Therefore, we decided that the Plan does not have to pay for initial hospital care (99222) provided on May 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass deluxe frames (V2025), progressive lenses (V2781), anti-reflective coating (V2750) and a miscellaneous vision item (V2799) provided on April 2, 2021.
You asked the Plan to pay for eyeglass deluxe frames, progressive lenses, anti-reflective coating and a miscellaneous vision item. You say that you were instructed by the Plan to see an out-of-network provider and told to submit forms with itemized bills. The Plan denied your request. The Plan says eyeglasses will only be covered when they are received from a provider in the specified vision network.
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 these services when they are received from a provider who participates in the Plan's specified vision network. We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's vision network, therefore, the service is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of eyeglass deluxe frames, progressive lenses, anti-reflective coating and a miscellaneous vision item have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass deluxe frames (V2025), progressive lenses (V2781), anti-reflective coating (V2750) and a miscellaneous vision item (V2799) provided on April 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve coverage for special supplemental benefits.
You asked the Plan to pre-approve coverage for special supplemental benefits. You say that you are requesting an appeal for special supplemental benefits. The Plan denied your request. The Plan says you do not have an eligible condition to receive these benefits.
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of special supplemental benefits have not been met. Specifically, we have confirmed that you do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-approve coverage for special supplemental benefits.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Abraxane.
You asked the Plan to pre-approve Abraxane. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Abraxane. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the 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 Abraxane have not been met. Therefore, we decided that the Plan does not have to pre-approve Abraxane.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Novolog.
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 drug is not eligible for a tier exception.
The Plan must follow Medicare rules. Medicare rules say that Part B drugs are not eligible for Part D tier exceptions. We looked at the file and Medicare rules. The requested drug, Novolog, is covered under Part B Medicare and not eligible for a Part D tier exception. 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 tier exception for Novolog.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
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 health plan's denial of LTACH coverage should be upheld. You are currently undergoing treatment at an acute care hospital (ACH) for Coronavirus. You were intubated/ventilated and subsequently received a tracheotomy. You are tolerating ventilator weaning. There is no evidence that you require 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 you to the LTACH. You can remain at the current ACH until such time no acute services are required. You can then be transferred/discharged to a lower level of care for any ongoing long-term care (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-approve long LTACH services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that there is a lack of bed and vent availability due to coronavirus (COVID-19) at the enrollee's current facility. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting. The LTACH would add no additional services
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 considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support long-term enteral feeding access has been established and is stable. The review indicates that continued acute care hospital services are required for this enrollee. We looked at this physician's review, the file, and Medicare rules. The provider in this case is asking for transfer to a LTACH to free up beds due to COVID-19. Based on this information, we decided that Medicare rules for coverage of the LTACH services have been met. Therefore, we decided that the Plan has to pre-approve long term acute care hospital (LTACH) services.
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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve percutaneous vertebral augmentation (PVA) for vertebrae T12 and L3.
You asked the Plan to pre-approve the requested PVA procedure. You say that the enrollee had an injury with findings of a subacute compression fracture. His daily functioning on his farm is impeded by the pain which is resistant to treatments that have been tried. The Plan denied your request. The Plan says that the enrollee does not meet criteria since the provider did not refer him for evaluation of bone density or recommend participation in an osteoporosis prevention/treatment program.
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. The rules also say that PVA is covered when the criteria listed in the Medicare rules section are met. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan's denial rationale is based solely on the absence of a stated plan in the medical record to evaluate bone density and recommend participation in an osteoporosis treatment program. The rules do not require these services to be provided prior to treatment. No argument was made that the other criteria were not met. Review of the records shows that the surgery was requested when the compression fracture was acute/subacute based on the imaging findings. The Plan did not coordinate care with its network surgeon or the enrollee's network primary care physician to ensure that the proper referrals were made for after the surgery was completed. It should be noted that the rules from the LCD were issued by a Medicare Administrative Contractor for Original Medicare beneficiaries in order to inform providers of the documentation required in order for the PVA to be reimbursed after it is completed. As such, prospective denial which would delay completion of a surgery solely due to a provider not documenting postsurgical plans in the preoperative examination notes cannot be reasonably considered to be the intent of the criteria cited as the denial rationale.
Therefore, we decided that the Plan has to pre-approve percutaneous vertebral augmentation (PVA) for vertebrae T12 and L3.
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 reimburse you for hearing aids (V5261) provided on January 28, 2021.
You asked the Plan to reimburse you for hearing aids. You say that you originally visited a provider and was approved $2,000 towards the purchase of hearing aids but the cost was $4,600. You also say that you found a provider online that sold hearing aids at a substantial lower amount. You are requesting reimbursement. The Plan denied your request. The Plan says in-network providers are available.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan contract says that you receive $2,000 towards the cost of two non-implantable hearing aid(s) every year. Routine hearing services must be received from a participating provider in order to be covered by the Plan. We looked at the file, and the Plan's rules. The records shows that the hearing aids were provided by an out-of-network provider. The Plan had network providers available who could have provided the items/services at issue in this appeal. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids (V5261) provided on January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) (E0466). You say that home BiPAP is not appropriate for meeting the enrollee's ventilatory requirements. The Plan denied your request. The Plan says the requested device would be used in a BiPAP mode.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) (E0466). Our reviewer says that a home ventilator is not medically necessary. Our physician reviewer found the patient is being treated for COPD, although there are no pulmonary function tests for confirmation. The patient retains CO2, at least during exacerbations. There is no evidence that BiPAP has been tried and failed. Certain BiPAP devices can provide the AVAPS mode of support, and Medicare does not cover a ventilator when used as BiPAP. The denial is upheld. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) (E0466) have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve end-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 4 or more face-to-face visits by a physician or other qualified health care professional per month (CPT code(s): 90960, 90961 and 90962) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the out-of-network services. You say that this provider is the only nephrologist in the area that sees patients at all three (3) dialysis facilities in the area. You state the enrollee started treatment at the facility with this provider over five (5) years ago and requires ongoing dialysis treatment several times a week and must continue seeing this provider to manage the enrollee's treatment. The Plan denied your request. The Plan says the medical record received did not show that the enrollee has an emergent or urgent medical condition or are in need of specialized service. The Plan states there are in-network provider(s) within a reasonable distance from the enrollee's location that can provide this service/item.
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 provider at issue in this case is not a network provider with the Plan. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the out-of-network services. Our physician reviewer found it is understandable that the enrollee would want to continue with their provider. There does not appear to be anything unique about this enrollee that would warrant the need for the use of an out-of-network provider. A similar level of care is offered by the enrollee's Plan. There is no evidence here that a circumstance exists that requires this particular provider. 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 out-of-network services have not been met.
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 the out-of-network services. Therefore, we decided that the Plan does not have to pre-approve end-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 4 or more face-to-face visits by a physician or other qualified health care professional per month (CPT code(s): 90960, 90961 and 90962) to be provided by an out-of-network provider.