Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that your request does not show that you have skilled nursing or therapy
needs that need to be provided on a daily basis as an inpatient only status.
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 your 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
You asked the Plan to pre-approve Vertiflex. You say that the enrollee has failed conservative approaches and is a good candidate for Vertiflex. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is a lack of evidence that this is as safe and effective as the gold standard of lumbar decompression.
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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental, more research is needed to show its 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
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 transfer to an IRF is medically necessary for this
enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The
enrollee can safely receive the services they need in an alternate setting.
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 the enrollee's 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 this
enrollee 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 treatment with Vascepa capsule.
You asked the Plan to pre-approve Vascepa capsule. You say that the requested treatment is a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered
drugs have not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Vascepa
capsule.
Benefits for Vascepa capsule 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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Gemcitabine (J9201) and Paclitaxel (aluminum bound) (J9264).
You asked the Plan to pre-approve the requested drug. You say that this is medically necessary to treat the
enrollee's cancer. The Plan denied your request. The Plan says that the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the requested drug. Our reviewer says
that the requested drugs Gemcitabine and Paclitaxel (aluminum bound) are medically reasonable and necessary
for the enrollee's condition. Our physician reviewer found the enrollee is a 73-year-old metastatic pancreatic
cancer biopsy proven with a diagnosis in January 2022. The request for these drugs was initially denied
because there was no liver function test. In this case, there are liver function tests from January 25, 2022, that
are acceptable and within normal limits. The requested drugs are FDA-approved for the enrollee's condition.
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 requested drug have been met. Therefore, we decided that the Plan has to
pre-approve Gemcitabine (J9201) and Paclitaxel (aluminum bound) (J9264).
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve portable oxygen concentrator. You say that you are unable to obtain this item from a local distributor because they have a backlog for these devices. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this provider is out-of-network with the Plan and you can receive an oxygen concentrator from an in-network provider.
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 a portable oxygen concentrator to be provided by an out-of-network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stelara (J3357).
You asked the Plan to pre-approve Stelara. You say that this medication is medically necessary for the enrollee's condition. 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 Stelara (J3357).
Benefits for Stelara 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre continuous glucose monitor sensors (K0553).
You asked the Plan to pre-approve Freestyle Libre sensors. You say that the item at issue is a necessity for your care. The Plan denied your request. The Plan says rules for coverage for CGMs and related supplies 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 indicates that you do not use insulin with at least
three daily injections. Based on this information, we decided that Medicare rules for coverage of Freestyle
Libre sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle
Libre continuous glucose monitor sensors (K0553).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits (99214) rendered by the out-of-network
(OON) provider on March 16, 2021 and March 23, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the office visits (99214) rendered by the out-of-network (OON) provider on
March 16, 2021 and March 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for fulvestrant injections provided from June
2, 2021, to June 30, 2021.
You asked the Plan to waive the coinsurance for the injections. You say that the Plan should cover all expenses
due to meeting your maximum out-of-pocket (MOOP) for the year. The Plan denied your request. The Plan
says the correct coinsurance was applied.
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 20%
coinsurance for Part B chemotherapy drugs.
You have been asked to pay $116.47 for each injection, which is 20% of the allowed amount for the injections
($582.35 allowed amount x 20% coinsurance = $116.47). The total for both visits is $232.94. However, the file
shows that your maximum out-of-pocket (MOOP) expenses were met during your second visit, resulting in you
being charged $91.47 over your MOOP. The Plan has indicated that this was adjusted on August 25, 2021,
showing your remaining responsibility of $141.47. The injections falls within the Medicare Part B Prescription
Drugs 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 fulvestrant injections provided
from June 2, 2021, to June 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an incentive spirometer (E1399).
You asked the Plan to pre-approve an incentive spirometer. You say that your doctor thinks that this would be very helpful for your condition that you have been dealing with for weeks. The Plan denied your request. The Plan says this item is considered a convenience item that is not primarily medical in nature and is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an incentive spirometer (E1399).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cataract surgery to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve cataract surgery. You say that you trust this doctor and do not want to switch providers. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network provider.
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 cataract surgery to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).
You asked the Plan to pre-approve the insertion of stabilization device (22869). You say that the rationale used to deny this service was incorrect. You say that the FDA approved this device in 2015 and Medicare supports it as well. The Plan denied your request. The Plan says the Vertiflex Superion Implant is not considered medically reasonable or 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 the insertion of stabilization device (22869). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that interlaminar distraction 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) have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you are unable to stand straight on your foot due
to pain. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6245) and two retainer crowns (D6740 x2).
You asked the Plan to pre-approve the pontic and retainer crowns. The Plan denied your request. The Plan says
these services are not covered.
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 a
pontic (D6245) and two retainer crowns (D6740 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0652) and Segmental
pneumatic appliance (E0667).
You asked the Plan to pay for a pneumatic compression device and appliance. You say that the enrollee would
benefit from a home compression pump. Her condition is severe and meets the need for lymphedema pumps.
The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced
lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either
E0650 or E0651.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance
provided. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device
(E0652) and Segmental pneumatic appliance (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a facet joint injection provided on September 16, 2021.
You asked the Plan to waive the coinsurance for the injection. You say that the procedure was not performed at a surgical center and you should not be responsible for that copayment. The Plan denied your request. The Plan says the correct coinsurance was applied.
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 20% coinsurance for each surgical visit at an outpatient hospital facility. You have been asked to pay $164.29, which is 20% of the allowed amount for the injection ($821.47 allowed amount x 20% coinsurance = $164.29). The injection falls within the Outpatient Surgery and Other Medical
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 a facet joint injection provided on September 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110).
You asked the Plan to pre-approve a denture. You say that you need a new denture now. You say that you are unable to each and chew your food well. The Plan denied your request. The Plan says 1 complete upper denture very 5 plan years. The Plan also says that the frequency limit has been reached.
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 complete upper denture is listed as covered, the frequency limit has been reached. The record shows that the Plan paid for a complete upper denture that you received on January 30, 2018. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intraperitoneal nutrition.
You asked the Plan to pre-approve the requested services. You say that the enrollee has severe malnutrition.
The Plan denied your request. The Plan says the enrollee's condition does not meet the guidelines.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.
We looked at the file and the rules. The file shows the services were requested to provide sufficient calories
and protein. The records do not show that the enrollee has a permanent impairment that impedes absorption of
nutrients.
Based on this information, we decided that the Medicare rules for coverage have not been met. Although the
services may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided
that the Plan does not have to pre-approve intraperitoneal nutrition.