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

We decided that the Plan does not have to pay for a stairlift (stair glide).
You asked the Plan to pay for a stair glide. You say that navigating the stairs in your home has resulted in falls
and injuries, so a stairlift was necessary. The Plan denied your request. The Plan says this device is not covered
by Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they
are not primarily medical in nature.
While a stair lift 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 pay for a stairlift (stair glide).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan
denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee was admitted with hypoxic respiratory failure due to Coronavirus
(COVID-19) pneumonia in the setting of receiving chemotherapy for acute myelogenous leukemia. The record
indicates that the enrollee continues to require high flow oxygen and is anemic. The record indicates that the
enrollee requires acute care services. The enrollee continues to receive acute care services, and these have not
been denied. The medical record does not indicate that the enrollee requires services that they are not currently
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not
satisfied. The requested service cannot be recommended.
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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that the enrollee has chronic urine and bowel incontinence. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Arestin.
You asked the Plan to pre-approve self-administered drug. You say that this medication is required for the
enrollee's treatment. The Plan denied your request. The Plan says the denial of authorization for this drug is
correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's
Medicare Part D prescription drug benefits.
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 Arestin.
Benefits for self-administered 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: 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 you need to be transferred to an IRF for additional
rehab services. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met.
Your ongoing skilled therapy needs are being met in the current skilled nursing facility.
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 your nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 you 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Imbruvica 420 mg tablet.
You asked the Plan to pre-approve Imbruvica. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.
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 Imbruvica 420 mg tablet.
Benefits for Imbruvica 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyewear provided on May 17, 2019.
You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says you must send the Plan
your request for reimbursement within 365 days from the date of service.
On April 6, 2021, the Plan received your eyewear reimbursement request for the items you received on May
17, 2019, which is past the timely filing limit.
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.
We looked at the file and the Plan's rules. The file shows that the Plan received your eyewear reimbursement
request for the items you received on May 17, 2019, which is past the timely filing limit. Therefore, we decided
that the Plan does not have to pay for eyewear provided on May 17, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve daily wound care/debridement services.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that two times per week can be approved.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested frequency of services are considered medically reasonable and necessary in this case. Our physician reviewer found you need this service more than two times per week, as you are getting more ulcers. 

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 services have been met. Therefore, we decided that the Plan has to pre-approve daily wound care/debridement services.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for vision services provided on
October 7, 2021.

You asked the Plan to pay an additional amount for vision services. The Plan denied your request. The Plan says the claim processed correctly.

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.

We looked at the file and the Plan's rules. The file shows that the Plan paid the claim correctly based on the Plan's vision benefit. Therefore, we decided that the Plan does not have to pay an additional amount for vision services provided on October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) provided on September 3, 2020.

You asked the Plan to pay for the office visit. You say that you would like this claim reprocessed. The Plan denied your request. The Plan says this claim has been filed after the timely filing deadline.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the office visit was not filed until October 4, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the office visit (99213) provided on September 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).

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 criteria for coverage are not met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 assesses adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that you do not treat with insulin. 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 Freestyle Libre continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that the items are medically necessary. The
Plan denied your request. The Plan says these are not covered items.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis tablet 5mg 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 self-administered medication does not fall under Part B 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 Eliquis tablet 5mg for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services (88305, 88312) provided on September 3,
2021, by an out-of-network (OON) provider.
You asked the Plan to pay for pathology services. You say that the doctor's office failed to send in a
preauthorization from for approval. The Plan denied your request. The Plan says this provider is a non-
participating provider, and the member was referred by a non-participating provider. The Plan also says that
they have also determined 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 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 pathology services (88305, 88312) provided on
September 3, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent 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 denied as 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 Dupixent for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat lumbar epidural steroid injection (ESI) services.

You asked the Plan to pre-approve repeat lumbar ESI services. You say that the records provided support the need for the injection services in dispute. The Plan denied your request. The Plan says the requested injection is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that repeat ESI services are covered when medically necessary and for certain clinical criteria. 

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 repeat lumbar ESI services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found there was not significant pain improvement from the first ESI. Therefore, a second ESI is not indicated. The request is not medically necessary or reasonable.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of repeat lumbar ESI services have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat lumbar epidural steroid injection (ESI) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 and 22870),
fluoroguide for spine injection (77003) and moderate sedation services (99156).
You asked the Plan to pre-approve the insertion of stabilization device (22869 and 22870), fluoroguide for
spine injection (77003) and moderate sedation services (99156). You say that this condition is a major
contributor of disability, lost productivity and has greatly affected the member's quality of daily living. You say
that the minimally invasive implantation of spacer device is the most appropriate treatment for this patient and
is medically necessary. The Plan denied your request. The Plan says experimental and investigational
procedures are not 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 insertion of stabilization device
(22869 and 22870), fluoroguide for spine injection (77003) and moderate sedation services (99156). Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the Interspinous stabilization devices remain experimental. More research
is needed to show safety and efficacy.
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 insertion of stabilization device (22869 and 22870), fluoroguide for spine
injection (77003) and moderate sedation services (99156) have not been met. Therefore, we decided that the
Plan does not have to pre-approve the insertion of stabilization device (22869 and 22870), fluoroguide for spine
injection (77003) and moderate sedation services (99156).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right shoulder surgery.
You asked the Plan to pre-approve right shoulder surgery. You say that this surgery is medically necessary. The
Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of the
surgery.
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 right shoulder surgery. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable,
and comprehensive less invasive conservative care measures. There are limited large-scale, long-term
references showing the safety and efficacy of the requested surgery without trial of conservative care measures.
The magnetic resonance imaging (MRI) does not demonstrate significant deficits that would require surgery
prior to conservative care measures. There is no compelling rationale presented or extenuating circumstances
noted to support the medical necessity of this request as an exception.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of right shoulder surgery have not been met. Therefore, we decided that the Plan
does not have to pre-approve right shoulder surgery.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha (J3590).

You asked the Plan to pre-approve Repatha. You say that the enrollee is statin intolerant. You say that the 
enrollee is tolerating Repatha well. You also say that the enrollee would like to continue receiving these 
injections. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare Part B.

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 Repatha (J3590).

Benefits for Repatha 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the second opinion services to be provided by an OON
provider.
You asked the Plan to pre-approve the second opinion services. You say that this is medically necessary for
your condition. The Plan denied your request. The Plan says they have in-network providers that are available
to provide the care you need.
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
the second opinion services to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 very heavy duty power operated vehicle (POV).

You asked the Plan to pre-approve a Group 2 very heavy duty POV. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that if a Group 2 POV is provided it will be denied as not reasonable and necessary. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Group 2 very heavy duty POV have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 very heavy duty power operated vehicle (POV).