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

We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) machine and accessories.

You asked the Plan to pre-approve a CPAP machine and accessories. You say that the records provided support the need for the items in dispute. The Plan denied your request. The Plan says the documentation provided does not include abnormal sleep study results. The Plan says that the items in dispute are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a CPAP machine and accessories. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested items are not medically necessary because coverage criteria have not been met. The enrollee has been given a diagnosis of obstructive sleep apnea, but the medical record does not provide any information about previous sleep studies, previous use of CPAP, or current sleep symptoms. There is no information on CPAP compliance. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CPAP machine and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) machine and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide additional payment for the lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass (V2782) and anti-reflective coating (V2750) provided October 1, 2021.  You asked the Plan to provide additional payment for the lenses and anti-reflective coating. You say that you would like additional payment for the eyewear. The Plan denied your request. The Plan says your full routine eyewear allowance was applied to your eyeglasses. You are responsible for the remaining cost.  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 routine eyewear up to a $250 allowance.  We looked at the file and the Plan's rules. In this case the Plan provided documentation showing that your full $250 allowance was applied to your routine eyewear purchased on October 1, 2021. Therefore, the remaining cost is your responsibility. Therefore, we decided that the Plan does not have to provide additional payment for the lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass (V2782) and anti-reflective coating (V2750) provided October 1, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) (G0299) and direct skilled nursing services of a licensed practical nurse (LPN) (G0300).    You asked the Plan to pre-approve the direct skilled nursing services of an RN and LPN. You say that this request for the home health services should be reconsidered because the care is medically necessary for the enrollee. The Plan denied your request. The Plan says supporting documentation has not been received to approve these services.  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 the direct skilled nursing services of an RN and LPN. Our reviewer says that ongoing home health services are not shown to be medically necessary or reasonable. Our physician reviewer found the enrollee does not have documented skilled nursing needs. Our reviewer also found that the enrollee does not have documented skilled therapy 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 direct skilled nursing services of an RN and LPN have not been met. Therefore, we decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) (G0299) and direct skilled nursing services of a licensed practical nurse (LPN) (G0300).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Duloxetine 30 mg capsule.

You asked the Plan to pre-approve Duloxetine. You say that this drug is medically reasonable and necessary.
The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.

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 Duloxetine 30 mg capsule.

Benefits for Duloxetine 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.  You asked the Plan to pre-approve the SNF admission. You say that if you do not go to a SNF soon for immediate care and physical therapy, you may not get back to your normal way of functioning. The Plan denied your request. The Plan says your request for approval of an admission to a SNF from home does not meet the requirements for approval.  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. Our reviewer found that you do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.  We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, these needs are not on a daily basis. 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 a skilled nursing facility (SNF) admission.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Actemra.

You asked the Plan to pre-approve Actemra. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because Actemra is not medically necessary for the enrollee's condition.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Actemra. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of Actemra. Our physician reviewer found the requested use of intravenous (IV) Actemra is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. This use is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office consultation (99243) and orthotic occlusal device (D7880) provided on June 10, 2021.  You asked the Plan to pay for the outpatient services. You say that the services should be covered. The Plan denied your request. The Plan says the services in this case are assigned a Status Indicator of "I". The Plan also says that services with a Status Indicator of "I" are not payable.  The Plan must follow Medicare rules. Medicare rules say that services with a Status Indicator of "I", indicating that this code is not valid for Medicare purposes and is not payable.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been met. Therefore, we decided that the Plan does not have to pay for the office consultation (99243) and orthotic occlusal device (D7880) provided on June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive eye exam (92004) and refraction services (92015) provided June 3, 2021.  You asked the Plan to pay for the vision services. You say that you tried to contact network providers but was unsuccessful. This doctor had an appointment available for the following morning. The Plan denied your request. The Plan says services obtained from vendors outside the network are not covered. This provider was not certified/eligible to be paid for this procedure on this date of service.  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 rendered by a Plan vision network vendor.  We looked at the file and the Plan's rules. Enrollee's must receive their vision services from an in-network provider Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive eye exam (92004) and refraction services (92015) provided June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the progressive lenses (V2781), ultraviolet lenses (V2755), and anti-reflecting coating (V2750) provided September 17, 2021.  You asked the Plan to pay for the progressive, ultraviolet and anti-reflecting lens upgrades. You say that the new lenses were necessary because your old ones were not working. The Plan denied your request. The Plan says these lens upgrades are not covered under your benefits. The upgrades are available at a discounted savings. The Plan contacted the provider who confirmed you were overcharged by the provider by $10, and this has been reimbursed to you.  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 does not cover routine lens enhancements including progressive, ultraviolet and anti-reflective coating upgrades.  We looked at the file and the Plan's rules. Though the Plan offers routine vision benefits in excess of Medicare coverage, the progressive, ultraviolet and anti-reflective lens upgrades are not among those covered services. Therefore, we decided that the Plan does not have to pay for the progressive lenses (V2781), ultraviolet lenses (V2755), and anti-reflecting coating (V2750) provided September 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with computed tomography (CT) scan.  You asked the Plan to pre-approve a PET CT scan. You say that this imaging service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this imaging service is not covered by Medicare for the enrollee's medical condition.  The Plan must follow Medicare rules. Medicare rules say that a PET scan will not be covered for initial treatment strategy related to prostate cancer. This service is specifically requested for the enrollee's newly diagnosed prostate cancer. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with computed tomography (CT) scan.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with computed tomography (CT) scan.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an outpatient surgery (36821) performed on June 1, 2021.  You asked the Plan to waive the copayment for the outpatient surgery. You say that the services should be covered as the surgery was incomplete. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.   You have been asked to pay a $200 copayment for an outpatient surgery. The record indicates that these services were performed in an outpatient setting 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 an outpatient surgery (36821) performed on June 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) provided August 3, 2020.  You asked the Plan to pay for the complete series of intraoral x-rays. You say that you have zero copayments for Medicare and Medicaid. The Plan denied your request. The Plan says this service is not covered under your benefits.  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 pay for the intraoral - complete series of radiographic images (D0210) provided August 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.

You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied
your request. The Plan says there is no indication that the mobility limitations within the home cannot be
sufficiently and safely resolved by the use of an optimally-configured manual wheelchair.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the wheelchair. Our reviewer says that
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the
documentation does not support that you have a mobility limitation that impairs MRADLs in the home. There
is no home assessment to support that the requested device will be able to safely maneuver in the home, and
access rooms for MRADL participation. The documentation does not support that this wheelchair will
significantly improve your ability to participate in MRADLs, and that you will use it in the home.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the wheelchair have not been met. Therefore, we decided that the Plan does not
have to pre-approve a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the cataract surgery (66984) provided on July 21, 2021 and August 24, 2021.

You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.

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 copayment per visit for a specialist office visit. Covered services include medically-necessary medical care or surgery services furnished in a physician's office, certified ambulatory surgical center, hospital outpatient department, or any other location. Consultation, diagnosis, and treatment by a specialist are covered. 

You have been asked to pay $100 ($50 copayment x 2) for the specialist services provided. The medical record indicates that the surgery provided in this case was co-managed by this provider. 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 copayments for the cataract surgery (66984) provided on July 21, 2021 and August 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex device.  You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.  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 device. 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 chronic low back pain and lumbar spinal stenosis with claudication. The record indicates that the enrollee has imaging that demonstrates multi-level disease with severe central stenosis at L2-L3 and L4-L5 and moderate stenosis at L3-L4. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Wellbutrin.  You asked the Plan to pre-approve Wellbutrin. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.    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 Wellbutrin.   Benefits for Wellbutrin 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI (78452) provided on August 6, 2019.

You asked the Plan to waive the copayment for the MRI. You say that the services should be covered and you received the bill two years later after it was sent to an old address. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.

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 $325 copayment for Outpatient diagnostic tests and therapeutic services and supplies.

You have been asked to pay a $325 copayment for an MRI. MRI's fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an MRI (78452) provided on August 6, 2019.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.  You asked the Plan to pre-approve SNF services. You say that the enrollee cannot safely discharge home and would greatly benefit from a SNF stay. The Plan denied your request. The Plan says that the member has no daily skilled nurse or therapist needs.  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 necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services.  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 skilled nursing facility (SNF) services for the enrollee.