Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of home health aide (HHA) services.
You asked the Plan to pre-approve the HHA services. You say that the enrollee has pain in joints and recently
had a fall. She lives alone and does not have the physical ability to bath or do any physical activity. The Plan
denied your request. The Plan says the enrollee does not meet the criteria as the service is not required to
maintain the enrollee's health or facilitate treatment of injury. The services are provided to assist with homemaker services.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or therapy.
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 HHA services. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case.
Our physician reviewer found in this case, the documentation doesn't support that the enrollee requires skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The enrollee does not require skilled nursing or rehab services 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 exacerbation of chronic medical problems or hospitalizations. She no longer requires the services of a home health aide. 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 the HHA services have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of home health aide (HHA) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the limited oral evaluation (D0140), provided on October 1, 2021.
You asked the Plan to pre-approve the limited oral evaluation. You say that the service should be covered. The
Plan denied your request. The Plan says you have exceeded the maximum allowance for this 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 limited oral evaluation (D0140), provided on October 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for skin grafting of the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits surgical services (J0690, 15120, C1729, J2405) rendered on August 3, 2021.
You asked the Plan to waive the coinsurance for skin grafting of the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits surgical services. You say that you were told the hospital accepts this Plan as full payment and now you received a bill for over $3,000. You also say you are a 74 year old disabled female on disability and cannot afford this. 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 50% coinsurance for out-of-network outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay $3,273.70 in coinsurance, which is 50% of the allowed amount for skin grafting of the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits surgical services ($6547.41 allowed amount x 50% = $3273.70). Skin grafting of the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits surgical services falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 coinsurance for skin grafting of the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits surgical services (J0690, 15120, C1729, J2405) rendered on August 3, 2021.
Your complaint about the hospital potentially misinforming you of the cost sharing amount you would be responsible for is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you do not require services at the LTACH that are not available at another level of 
care. There are no services available at the LTACH that you require that are not available at the health care 
setting being offered by the health plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nyvepria. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has acute myeloid 
leukemia. The use of Nyvepria is not indicated for the treatment of myeloid malignancies. Cytopenias on 
ventoclax/azacitabine should be treated with dose adjustments. The service is not reasonable or medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Nyvepria.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you have a place to store the scooter in your 
basement. The Plan denied your request. The Plan says your home is not accessible. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
We looked at the file and the rules. The records show that your home does not provide adequate access for the 
requested scooter. The item at issue appears to be needed for use outside of the home. Based on this 
information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power scooter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Metformin ER tablet 100mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is a benefit exclusion.
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 Metformin ER tablet 100mg for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says your medical records indicate that you have no current skilled nursing needs and the current non-skilled nursing needs can be managed at a lower level of care, such as returning home with home health care services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, you received oral medications. You had stable vital signs. You were treated for pain, fevers and cellulitis. Regarding rehabilitation services, you received physical therapy (PT) and occupational therapy (OT). By the dates in question, you were at a standby assist to minimal assist level with functional mobility including gait from 50-149 feet with a rolling walker. You required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on November 1, 2021.
You asked the Plan to pay for the dental service. You say that you cannot afford any extra bills. You say that
you are on a fixed income. You say that you were not aware of your benefits breakdown. You also say that it is
not your fault that you had to get a new dentist. The Plan denied your request. The Plan says 1 comprehensive
oral evaluation is covered every 3 plan years. The Plan also says that the frequency limit has been exceeded.
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 service is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on March 11, 2020. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on November 1, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vascular study (93975) provided on November 2, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the vascular study. You say that the services provided were medically necessary 
and you would like this claim to be reconsidered for coverage. The Plan denied your request. The Plan says 
these services were not rendered or referred by a network provider or rendered in an in-network facility. The 
Plan also says that these services are not urgent or emergent, nor were they approved in advance. 
 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. 
Therefore, we decided that the Plan does not have to pay for the vascular study (93975) provided on November 
2, 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 all lower extremity prostheses, flex-walk system or equal (CPT code L5981), addition, endoskeletal system, below knee, flexible protective outer surface covering system (CPT code L5962), and all lower extremity prostheses, multi-axial rotation unit ('mcp' or equal) (CPT code L5986).
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your request. The Plan says the records they have do not show why the requested prosthesis with an advanced foot is needed. The Plan states the request for K3 foot does not meet Medicare criteria as reasonable and necessary. The Plan states a request for a prosthetic foot (K2) that meet the enrollee's needs and Medicare guidelines can be reviewed if submitted.
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 items. Our physician reviewer found your records did not show that you currently have K3 status ambulation. You have an antalgic gait, and the physician did not state why K3 (over K2) prosthesis would be more appropriate for you. There was no explanation in the notes as to why a K2 ambulator prosthesis would not be appropriate for you. Therefore, you do not meet LCD criteria for this device. 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 items have not been met. Therefore, we decided that the Plan does not have to pre-approve all lower extremity prostheses, flex-walk system or equal (CPT code L5981), addition, endoskeletal system, below knee, flexible protective outer surface covering system (CPT code L5962), and all lower extremity prostheses, multi-axial rotation unit ('mcp' or equal) (CPT code L5986).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this medication was denied due to benefit exclusion. 
 
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 Eliquis.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF admission. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a skilled nursing facility (SNF) setting. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Breztri Aerosphere Aerosol 160/9/4.8/MCG/ACT for 
the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this might be covered under Part D. 
 
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 Breztri Aerosphere Aerosol 
160/9/4.8/MCG/ACT for the enrollee.  
 Benefits for the drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment(s) (93702).
You asked the Plan to pre-approve bioimpedance spectroscopy. You say that the enrollee has a high risk of developing lymphedema following breast cancer treatment in 2019, and this service is medically necessary. The Plan denied your request. The Plan says bioimpedance for the detection of lymphedema is considered experimental/investigational in nature, and therefore this service is 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 bioimpedance spectroscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that this enrollee with a history of breast cancer, status post right breast mastectomy in 2019, underwent physical therapy for lymphedema reduction and has used a compression sleeve with good control of lymphedema. A request was made for bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment(s) (93702). The enrollee already has the diagnosis of lymphedema, which is already being treated effectively with compression. BIS testing will not provide any significant information or lead to any change in treatment that would lead to improved outcomes for this enrollee. There was no exceptional information provided in the records to justify this request. Therefore, the BIS testing will be considered not medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bioimpedance spectroscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment(s) (93702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CGM system and standard supply allowance for this device (CPT code(s): K0553 and K0554), for the enrollee.
You asked the Plan to pre-approve the CGM and supplies. You say that the CGM and supplies is necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation does not show that the enrollee is insulin-treated with multiple (three of more) daily injections of insulin, or a continuous subcutaneous insulin infusion (CSII) pump and the documentation does not show the enrollee is insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results. Based on this information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a CGM system and standard supply allowance for this device (CPT code(s): K0553 and K0554), for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for psychotherapy provided on September 21, 2021.
You asked the Plan to pay for the psychotherapy. You say that the documents should be reviewed, and the
claim processed for payment. The Plan denied your request. The Plan says that there was no documentation of
contact with the primary care physician in the medical records.
The Plan must follow Medicare rules. Medicare rules say that documentation of a consultation with the
attending or primary care physician does not apply if the physician referred the patient to the Clinical
Psychologist.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the psychotherapy have been met. Specifically, the submitted claim includes a referring provider.
Documentation of a consultation is not required when there is a referring physician. Therefore, we decided that
the Plan has to pay for psychotherapy provided on September 21, 2021.
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.