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

 We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (CPT code E2311), for the enrollee.  You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the Medicare rules have not been met. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Medicare Guidance says that upgraded electronics are not medically needed, as there is no medical need to control power options though the joystick. Therefore, we decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (CPT code E2311), for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring (G0453) provided on December 21, 2020.  You asked the Plan to pay for code G0453. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  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, we have confirmed that code G0453 is a column II code to column I code 95961. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring (G0453) provided on December 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve power seat elevation system (CPT code E2300), for the enrollee.  You asked the Plan to pre-approve the DME. You say that the enrollee is unable to reach certain things a high height and feel the enrollee will benefit from the DME. The Plan denied your request. The Plan says this is not covered. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve power seat elevation system (CPT code E2300), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Belbuca 150mcg.  You asked the Plan to pre-approve Belbuca. You say that Belbuca is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B 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 Belbuca 150mcg.   Benefits for Belbuca 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: Favorable

 We decided that the Plan has to pay for the acute inpatient hospital care.  You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient stay should be approved. The Plan denied your request. The Plan says that the request for inpatient hospitalization is not medically necessary at this time.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that in this case the enrollee has been referred for what appears to be a 3-4 day long term electroencephalography (EEG) recording. According to the applicable regulation, Medicare covers the inpatient level of care when an episode of care will span at least two midnights. Based on the information provided for review with this request, the proposed admission will span the two midnights as required by the regulation. As such this would meet requirements for the inpatient level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care.     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: 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 admission. You say that this is medically necessary. The Plan denied your request. The Plan says the services required can be provided in a different setting, for example, home with home health, in residential care, or home with close follow-up with the doctor.  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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, there is no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to provide medically necessary and reasonable treatment safely and effectively. Daily skilled services are not required. You do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate in this case.  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 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you more than the benefit amount for eyeglasses provided on February 24, 2021.  You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. The Plan says the Plan will reimburse you the eyewear benefit allowance of $200.00 and the $261.40 is over and above the allowance amount.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The file shows that the Plan will reimburse you the maximum eyewear benefit allowance of $200.00 and the $261.40 is over and above the allowance amount. Therefore, we decided that the Plan does not have to reimburse you more than the benefit amount for eyeglasses provided on February 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on May 7, 2020.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered screening test.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on May 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Ruxience 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 drug is not helpful for treatment of von Willebrand disease.  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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of  acquired von Willebrand's disease. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare-approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation.           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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Ruxience for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power wheelchair tie-down kit (K0108).  You asked the Plan to pre-approve the power wheelchair tie-down kit.. You say that this accessory is medically necessary. The Plan denied your request. The Plan says items for use outside the home are non-covered.  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.   The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair tie-down kit (K0108).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychotherapy visit provided on June 15, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the psychotherapy visit. You say that a Plan representative sold this insurance to the enrollee without any knowledge that the provider was out-of-network and that telehealth visits were not covered. The Plan denied your request. The Plan says no prior authorization was obtained.  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 the psychotherapy visit provided on June 15, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services (G0483) provided on June 17, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not supported.  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 G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed".  We find that CPT code G0483 is not supported in the medical record. Specifically, the records provided do not show that 22 or more drug classes were tested on the date of service in question. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0483) provided on June 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).  You asked the Plan to pre-approve therapeutic CGM. You say that you experience extreme fluctuations of blood sugars and need this monitor to alert you and help you keep better control. The Plan denied your request. The Plan says you do not meet the Medicare criteria for a therapeutic CGM.  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 indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a gym initiation fee.  You asked the Plan to pay for a gym initiation fee. The Plan denied your request. The Plan says gym initiation fees are not a covered benefit.  The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   The Plan's rules for coverage of gym benefits have not been met because the Plan does not reimburse for a gym initiation fee as a covered fitness benefit. Therefore, we decided that the Plan does not have to pay for a gym initiation fee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve minimally-invasive percutaneous sacroiliac fusion.  You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says the effectiveness of this request has not been demonstrated in the peer-reviewed literature.  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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested procedure remains experimental. More research is needed to show the safety and efficacy of minimally-invasive percutaneous sacroiliac fusion.  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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve minimally-invasive percutaneous sacroiliac fusion.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 We decided that the Plan has to pay for the limited oral evaluation provided on October 29, 2020. We decided that the Plan does not have to pay for the deep sedation provided on October 29, 2020.   You asked the Plan to pay for the limited oral evaluation and deep sedation provided on October 29, 2020. You say that the denied amount should be paid under medical coverage since the dental limit is exhausted. The Plan says that the services are dental in nature and are not covered under the medical benefit.  We decided that the Plan has to pay for the limited oral evaluation provided on October 29, 2020.   The Evidence of Coverage clearly says that you pay a $0 copayment for oral exams. The Evidence of Coverage does not list a frequency for how many oral exams can be provided in a calendar year. There was also no documentation submitted showing your yearly maximum limit for dental coverage has been met. Therefore, we decided that the Plan has to pay for the limited oral evaluation provided on October 29, 2020.   We also decided that the Plan does not have to pay for the deep sedation provided on October 29, 2020.  The Evidence of Coverage includes a list of covered supplemental dental benefits. Anesthesia is not listed as a covered benefit. Therefore, we decided that the Plan does not have to pay for the deep sedation provided on October 29, 2020.  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 Durolane (J7318).  You asked the Plan to pre-approve Durolane. You say that Durolane is medically necessary. The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives like Durolane can be considered.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Durolane. Our reviewer says that Durolane is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drugs or any reason why they would be unsafe or ineffective for this patient.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane (J7318).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the gingival irrigation (D4921) provided on March 1, 2021.  You asked the Plan to pay for the gingival irrigation (D4921). You say that you paid out-of-pocket and should be reimbursed. The Plan denied your request. The Plan says the service is not a covered 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 pay for the gingival irrigation (D4921) provided on March 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Vertiflex superion device placement surgery for the enrollee.  You asked the Plan to pre-approve these services. You say that the enrollee needs this to treat lumbar spinal stenosis with neurogenic claudication. The Plan denied your request. The Plan says that 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex superion device placement surgery for the enrollee.