Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on June 10, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the DRG was changed from 871 to 689, due to the removal of the principal diagnosis code for sepsis and the secondary diagnosis code for severe sepsis without septic shock.

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 871 (SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC). 

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 services. Our reviewer says that the services Our physician reviewer found despite presentation with an infected heel ulcer, possible urinary tract infection, and elements of the Systemic Inflammatory Response Syndrome (SIRS), the hospital record does not support reporting a diagnosis of Sepsis for this hospital admission. The review has determined that DRG 689: KIDNEY AND URINARY TRACT INFECTIONS WITH MCC was the appropriate DRG. 

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 services provided to the enrollee on June 10, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda in combination with Xeloda.

You asked the Plan to pre-approve Keytruda in combination with Xeloda. You say that the requested Keytruda in combination with Xeloda is medically necessary. The Plan denied your request. The Plan says that the requested Keytruda in combination with Xeloda is not medically necessary.

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 in combination with Xeloda. Our reviewer says that the requested Keytruda in combination with Xeloda is medically necessary. Our physician reviewer found the use of Keytruda in combination with Xeloda is not FDA-approved for the enrollee's diagnosis. The use is supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The National Comprehensive Cancer Network (NCCN) Guidelines supports adjuvant pembrolizumab in those patients with high-risk triple negative breast cancer that did not receive it in the neoadjuvant setting. As capecitabine is indicated in patients with residual disease after NACT and the KEYNOTE study included pembrolizumab (NCCN Guidelines Version 2.2022: Invasive Breast Cancer). The documentation supports 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 Keytruda in combination with Xeloda have been met. Therefore, we decided that the Plan has to pre-approve Keytruda in combination with Xeloda.

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 pre-approve a crown (D2750) for tooth # 31.
You asked the Plan to pre-approve the dental service. You say that this service should be approved. The Plan denied your request. The Plan says 1 crown is covered 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 crown is listed as covered, the frequency limit has been reached. The record shows that the Plan paid for a crown for tooth # 31 that you received on October 31, 2019. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6241) for tooth #14 and retainer crowns (D6751) for tooth #'s 13 and 15.

You asked the Plan to pre-approve the pontic and retainer crowns. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services exceed the maximum counts allowed per period.

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, pontic (D6241) and retainer crown (D6751) are each limited to one procedure per tooth every five plan years. The record shows that you received a pontic (D6241) on tooth #14 and retainer crowns (D6751) on tooth #'s 13 and 15 on February 8, 2019 and your pontic (D6241) benefit for tooth #14 and retainer crown (D6751) benefit for tooth #'s 13 and 15 have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a pontic (D6241) for tooth #14 and retainer crowns (D6751) for tooth #'s 13 and 15.
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 enrollee requires an IRF admission. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met. The enrollee's ongoing skilled therapy and nursing needs can be provided at 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. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-ofnetwork
(OON) provider.

You asked the Plan to pre-approve a specialist office visit. You say that you have had problems with your eyes
such as glaucoma and the provider needs to follow up every four months. The Plan denied your request. The
Plan says these services are available within the Plan's network, and this would also not be considered an
emergency service.

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
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an addition, endoskeletal system, above the knee (L5950), a prosthetic sock, multiple plies, above the knee (L8430), a replacement socket above the knee (L5701), and a prosthetic sock, singly ply, fitting, above the knee (L8480) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve an addition, endoskeletal system, above the knee; a prosthetic sock, multiple plies, above the knee; a replacement socket above the knee; and a prosthetic sock, singly ply, fitting, above the knee. You say that to reroute the treatment to the Plan's suggested provider will make for an extremely far commute from your home and you would like to keep your treatment with this Provider. The Plan denied your request. The Plan says this service can be done with another, in-network provider who is within 22 to 25 miles.  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 an addition, endoskeletal system, above the knee (L5950), a prosthetic sock, multiple plies, above the knee (L8430), a replacement socket above the knee (L5701), and a prosthetic sock, singly ply, fitting, above the knee (L8480) to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cardiac computed tomography (CT) with calcium
scoring.
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 screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, cardiac CT with calcium scoring, is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve a cardiac computed tomography (CT) with calcium scoring.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a bath/shower chair.  You asked the Plan to pre-approve a bath/shower chair. You say that this item is medically necessary. The Plan denied your request. The Plan says bath and shower chairs and equipment are not covered by Medicare.  The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.   While a bath/shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a bath/shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve OON services. You say that it is difficult to draw blood out of the fingertips. The Plan denied your request. The Plan says there are in-network providers available.
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 at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that the requested compression stockings are medically necessary. The Plan denied your request. The Plan says Medicare does not cover the requested compression stockings.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a specialist office visit. You say that you are appealing with supporting records. The Plan denied your request. The Plan says there are participating providers in the member's area who are contracted with the Plan and accepting new patients within two weeks. The Plan also says that for the records received, there was no medical need shown as to why the enrollee cannot get movement disorder specialized care from a provider in the Plan network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eyeglass frames.
You asked the Plan to pre-approve eyeglass frames. You say that you had an eye exam on November 19, 2021 and you were given a new prescription. You say you got a stroke two years ago and you have Type 2 diabetes, and you cannot wait until October to get a new pair of eyeglasses. The Plan denied your request. The Plan says that the Plan's records show you will be eligible for new eyeglasses in October 2022.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services every two years.
We looked at the file and the Plan's rules. The file shows you received the eyewear benefit for a pair of eyeglasses in 2020 and you are not eligible for the eyewear benefit until October 1, 2022. Based on this information, we decided that the Plan's rules for coverage of eyeglass frames have not been met. Therefore, we decided that the Plan does not have to pre-approve eyeglass frames.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the requested
out-of-network provider.
You asked the Plan to pre-approve the requested out-of-network physician's services. You say that you need your eye measured for cataract surgery. The Plan denied your request. The Plan says while you are a member of the Plan, you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed care, out-of-area dialysis services, or when the providers in our network cannot provide this care.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the requested out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #20.

You asked the Plan to pre-approve the crown. You say that you understand you only get two crowns at $0 cost,
but you are requesting an exception for a third crown to be made because you were not able to get dental
service since 2019 due to the Coronavirus pandemic. You also say that you were advised that if you wait until
next year, your tooth condition may get worse. The Plan denied your request. The Plan says your crowns
benefit has been exhausted.

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, crown(s) are limited to two procedure
codes per calendar year. The record shows that you were approved for crowns (D2740) for tooth #'s 6 and 7.
Crowns were not provided for tooth #'s 6 and 7 in 2021, therefore, once billed, these will utilize your 2022
crowns benefit. Therefore, your benefit has been exhausted for the 2022 plan year. Therefore, we decided that
the Plan does not have to pre-approve a crown (D2740) for tooth #20.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthroscopic knee surgery (29881).
You asked the Plan to pre-approve arthroscopic knee surgery. You say that this is medically necessary. The Plan denied your request. The Plan says this is not supported at this time.
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 arthroscopic knee surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not document a recent and reasonable trial of comprehensive conservative care measures. Additionally, there are no formal advanced imaging studies provided that corroborate a meniscal tear for which the procedure would be indicated.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of arthroscopic knee surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve arthroscopic knee surgery (29881).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implant placement (D6010) for tooth # 29.
You asked the Plan to pre-approve the dental service. You say that you cannot eat solid food. You say that your teeth are moving around. You also say that you have been having this issue for the last month and a half. The Plan denied your request. The Plan says dental implants and all associated services are excluded from coverage.
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 implant placement is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve implant placement (D6010) for tooth # 29.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature (L5968) and all lower extremity prostheses, flex-walk system or equal (L5981).
You asked the Plan to pre-approve the advanced feet and rotational units. You say that the proposed feet will provide enhanced stability and increase the enrollee's confidence on uneven surfaces as a bilateral amputee. The Plan denied your request. The Plan says the request for K3 feet does not meet Medicare criteria as reasonable and 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 the advanced feet and rotational units. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that meets the requirements listed in the LCD for Medicare coverage for the advanced K3 level prosthetic feet. Records indicate the enrollee requires a wheelchair for longer distances and for nighttime use (even with the requested equipment). Records do not support that the enrollee is at a K3 ambulatory level to support the requested advanced K3 level prosthetic feet. 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 advanced feet and rotational units have not been met. Therefore, we decided that the Plan does not have to pre-approve addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature (L5968) and all lower extremity prostheses, flex-walk system or equal (L5981).