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

We decided that the Plan does not have to pre-approve the wheelchair accessory, power seat elevation system
(E2300).

You asked the Plan to pre-approve power seat elevation system. You say that you are requesting
reconsideration of the seat elevation system and consider it to be an essential accessory for coverage. The Plan
denied your request. The Plan says this item is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We looked at the file, and Medicare rules. A power seat elevation feature is not covered because they are not
primarily medical in nature. Based on this information, we decided that Medicare rules for coverage of power
seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve the
wheelchair accessory, power seat elevation system (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services provided to the enrollee on June 14, 2021. 
 You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on June 14, 
2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 coded C9803 provided on January 21, 2021.  You asked the Plan to pay for hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code C9803 is hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source.  We find that CPT code C9803 is not supported in the medical record. Specifically, this code was billed with bill type 14X. This code is not payable with this bill type billed. Based on this information, we decided that Medicare rules for coverage of hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 have not been met. Therefore, we decided that the Plan does not have to pay for hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 coded C9803 provided on January 21, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health occupational therapy visits.

You asked the Plan to pre-approve home health care. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for the requested home health care is correct, because the records do not support a need for a skilled therapist.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 health care. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested home health care. Our physician reviewer found the enrollee does not require additional skilled nursing or skilled therapy visits to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. She has received ample skilled therapy to establish a home exercise program that she and her caregivers can do at home. The requested home health services are 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 home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve home health occupational therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve electric cell-signaling treatments with the Sanexas 
device. 
 You asked the Plan to pre-approve the Sanexas device treatments. You say that you feel that this should be 
covered as it may help your condition. The Plan denied your request. The Plan says this is an experimental 
therapy and cannot be covered by Medicare. 
 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 Sanexas device treatments. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the record indicates that the enrollee has lower extremity peripheral 
neuropathy. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.  
 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 Sanexas device treatments have not been met. Therefore, we decided that 
the Plan does not have to pre-approve electric cell-signaling treatments with the Sanexas device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair.

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 covered.

The Plan must follow Medicare rules. The rules say that Medicare will replace durable medical equipment (DME) only in instances of irreparable damage or if the equipment is more than five years old. 

We looked at the file and Medicare rules. The file shows you received a manual wheelchair in 2018. The file does not show that your current manual wheelchair is irreparably damaged or more than five years old. 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 manual wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fold down bedrail.

You asked the Plan to pre-approve a bed rail. You say that you had coded in the hospital before and has to sleep with wedge pillows to prop you up. You feel the requested bedrails will better suit you. The Plan denied your request. The Plan says this item is not primarily used to serve a medical purpose.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a fold down bedrail.
Appeal type: DME/ Orthotics
Decision: Favorable

 We decided that the Plan has to pre-approve an implantable defibrillator placement (33249, C1721, C1722). 
 You asked the Plan to pre-approve the implantable defibrillator placement. You say that the device is medically 
necessary. The Plan denied your request. The Plan says that coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that implantable defibrillators are covered when 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 implantable defibrillator placement. 
Our reviewer says that the requested defibrillator is medically necessary. Our physician reviewer found the 
patient has Class III symptoms of heart failure while on guideline directed medical therapy. She has had 
calculations of ejection fraction by multiple methods including Single photon emission computed tomography 
(SPECT) at 20%, Echocardiography at 37%, and a multigated acquisition (MUGA) scan at 36%. Although 
very minimally above the 35% cutoff on the MUGA scan, this difference is well within the margin of error of 
the scan and the actual result could be at or even somewhat below the 35% cutoff based on the known test 
variation of 4-8%. When coupled with ongoing Class III symptoms, her risk of sudden death would be high 
enough to warrant internal defibrillator placement given the clinical situation, the various results of the ejection 
fraction assessments, and the margin of error for the accuracy of the MUGA test. 
 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 implantable defibrillator placement have been met. Therefore, we decided 
that the Plan has to pre-approve an implantable defibrillator placement (33249, C1721, C1722).  
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methylphenidate tablets.

You asked the Plan to pre-approve Methylphenidate tablets. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.

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 Methylphenidate tablets.

Benefits for Methylphenidate tablets 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation therapy (36475).

You asked the Plan to pre-approve endovenous ablation therapy. You say that this is medically necessary. The
Plan denied your request. The Plan says this is not covered for the requested vein.

The Plan must follow Medicare rules. Medicare rules say that endoluminal radiofrequency ablation (ERFA)
and laser ablation are covered only for the treatment of symptomatic varicosities of the lesser or greater
saphenous veins and their tributaries which have failed 3 months of conservative therapy.

We looked at the file and Medicare rules. The ablation therapy at issue has been requested for a perforator vein.
Based on this information, we decided that Medicare rules for coverage of endovenous ablation therapy have
not been met. Therefore, we decided that the Plan does not have to pre-approve endovenous ablation therapy
(36475).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (pembrolizumab) injections.

You asked the Plan to pre-approve the Keytruda treatments. You say that it is felt this is medically necessary treatment for the enrollee. The Plan denied your request. The Plan says the documentation does not support the use of this drug in the enrollee's circumstance.

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 the Keytruda treatments. Our reviewer says that the requested drug is not shown to meet the Medicare criteria for medical necessity in this case. Our physician reviewer found the record indicates that the enrollee has a diagnosis of metastatic adenocarcinoma non-small cell lung cancer. The record indicates that genetic testing has not demonstrated EGFR or AK tumor aberrations but does not indicate the PD-L1 status of the tumor. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria are not satisfied. 

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 Keytruda treatments have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda (pembrolizumab) injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device. 
 
You asked the Plan to pre-approve the powered range of motion assist device. You say that this device is 
needed to allow the enrollee to have function of the arm. The Plan denied your request. The Plan says this is an 
experimental device and is not covered. 
 
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 powered range of motion assist 
device. Our reviewer says that the requested items are not considered medically reasonable and necessary in 
this case. Our physician reviewer found a powered upper extremity range of motion assist device is not 
indicated as it is not medically necessary.  The member had a stroke in the distant past. The current medical 
literature does not support the requested treatment as being effective in the treatment of hemiplegia/hemiparesis 
of the upper extremity. 
 
 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 powered range of motion assist device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received on
April 24, 2021, to April 26, 2021.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were in the
hospital last year and didn't get a bill. You said that you have never had to pay anything with this Plan. The
Plan denied your request. The Plan says after Original Medicare paid this bill, there was a balance of $135.44
remaining. Because this amount is less than your copayment with the Plan, you are responsible for the full
remaining amount.

The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan
contract says that enrollees must pay a $200 copayment for inpatient hospital care.

You have been asked to pay a $200 copayment for the inpatient hospital services. This cost sharing applies
regardless of what you may have paid in prior years. 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 inpatient hospital services you received on
April 24, 2021, to April 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on August 20, 2020. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on August 20, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a customized knee orthosis with adjustable flexion and 
extension joint coded as L1846. 
 You asked the Plan to pre-approve the customized knee brace. You say that you believe that the requested 
items should be approved. The Plan denied your request. The Plan says you do not meet Medicare criteria for 
the requested brace. 
 The Plan follows Medicare rules. Medicare rules say that knee braces are covered when the criteria from the 
Medicare rules section are met.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the customized knee brace. Our 
reviewer says that the documentation does not show that criteria for a knee brace are met. Our physician 
rviewer found the member has not had recent surgery or a recent injury. The documentation does not support 
that the joint is unstable or that there is joint laxity. The requested knee orthoses 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 the customized knee brace have not been met. Therefore, we decided that the Plan does not have to pre-approve a customized knee orthosis with adjustable flexion and extension joint coded 
as L1846.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on July 21, 2021.

You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.

Therefore, we decided that the Plan does not have to pay for out of network physician services provided on July 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided on May 18, 2021.

You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the code billed.

The Plan must follow Medicare rules. Medicare rules say that services of an occupational therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. Medicare rules say that the services of an occupational therapy assistant (OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the occupational therapy services have not been met. Specifically, the records do not indicate if the rendering provider was an occupational therapist or an OTA. There is no evidence that the nurse practitioner was on the premises to be able to bill for occupational therapy services. Additionally, the record does not include the rendering providers credentials, so we are unable to verify the billed services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided on May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network services provided to the enrollee on June 7, 
2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for out of network services provided to the enrollee on 
June 7, 2021.