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

 We decided that the Plan does not have to pre-approve a ROMTech portable rehabilitation exercise bicycle.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not 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. Therefore, we decided that the Plan does not have to pre-approve a ROMTech portable rehabilitation exercise bicycle.
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 IRF care is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of IRF care.  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 while you may benefit from therapy, you do not require the services at an IRF 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 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve proton beam radiation therapy as part of a clinical trial.  You asked the Plan to pre-approve the requested services. You say that the enrollee is enrolled in a phase II clinical trial. The Plan denied your request. The Plan says Original Medicare pays most of the cost of services you receive as part of the study.  The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services.  In this case, you asked the Plan to pre-approve the requested services as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve proton beam radiation therapy as part of a clinical trial.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the sacroiliac (SI) joint radio frequency ablation (RFA).  You asked the Plan to pre-approve the SI RFA. You say that you would like reconsideration because the requested procedure is medically necessary. The Plan denied your request. The Plan says RFA to nerves innervating SI joint is considered experimental/investigational.  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 SI RFA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational.  Studies completed say that this procedure does not improve outcomes compared to standard treatment of SI joint pain.  Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational.   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 SI RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve the sacroiliac (SI) joint radio frequency ablation (RFA).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that you require skilled services to improve your strength and increase your ability to perform activities of daily living at home. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.  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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for chemotherapy infusion services provided from June 15, 2021, to August 19, 2021.  You asked the Plan to waive the coinsurance for the chemotherapy infusion. You say that you would like to be reimbursed since the Plan sales representative lied about the coverage. 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 chemotherapy drugs.     Date of Service Allowed Amount 20% Coinsurance June 15, 2021 $14,568.29 $2,913.66 July 7, 2021 $17,196.64 $3,439.33 August 19, 2021 $17196.64 $846.61 (maximum met) Total:  $7,199.60  You have been asked to pay $7,199.60, which is 20% of the allowed amount for the chemotherapy infusion.  The charges for August 19, 2021, are reduced as you had met your maximum out of pocket (MOOP) expenses during this visit. The chemotherapy infusion 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 chemotherapy infusion services provided from June 15, 2021, to August 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve dental implants with an out-of-network (OON) provider.  You asked the Plan to pre-approve dental implants with an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you can receive the requested dental implants with an in-network Periodontics specialist.  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 when provided by an OON provider. The Plan has confirmed that there is an in-network Periodontics specialist you can see that can provide the dental implants you are requesting. Therefore, we decided that the Plan does not have to pre-approve dental implants with an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve StabiLink MIS Interspinous Fixation Device (CPT code 22840), for the enrollee.  You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of the StabiLink device in the setting of lumbar fusion have 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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the StabiLink device is 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve StabiLink MIS Interspinous Fixation Device (CPT code 22840), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve diabetic shoes with fitting to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the diabetic shoes with fitting. You say that the out-of-network provider is the only place where the shoes you needed are found. The Plan denied your request. The Plan says an In-Network provider was given that can provide this service.  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 diabetic shoes with fitting to be provided by an out-of-network (OON) provider.
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 IRF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of IRF care.  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 while the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  There is not a reasonable expectation that this patient 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: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health physical therapy services.  You asked the Plan to pre-approve the requested services. You say that you have improved dramatically with each round of physical therapy. The Plan denied your request. The Plan says the services are not medically necessary.  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.  The file shows that 8 home health physical therapy services were requested. The Plan has agreed to pre-approve 4 visits. 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 additional services. Our physician reviewer found that the documentation does not show that continued skilled therapy services are required to effectively provide treatment in order to improve your level of function, or to perform a maintenance program to maintain your level of function or prevent deterioration.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health physical therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve surgical dental extractions and sedation.  You asked the Plan to pre-approve surgical dental extractions and sedation. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says surgical dental extractions for the requested wisdom teeth are not covered under the Plan's supplemental dental benefit. The Plan says that the requested sedation is also not covered under the Plan's supplemental dental benefit.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.    Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical dental extractions and sedation.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a magnetic resonance imaging of the brain (70553) provided on August 31, 2021, by an out-of-network (OON) provider  You asked the Plan to pay for a magnetic resonance imaging of the brain. You say that you cannot afford to pay $6,567. You also say that you were not aware that your state is not a referral state. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in a participating facility. 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 a magnetic resonance imaging of the brain (70553) provided on August 31, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Gemtesa.  You asked the Plan to pre-approve Gemtesa. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B 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 Gemtesa.     Benefits for Gemtesa 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 pay for an office visit provided on October 20, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit. You say that you want to appeal the claim for payment denial. The Plan denied your request. The Plan says no prior authorization was obtained, and the provider is a non-participating provider with the Plan.  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 an office visit provided on October 20, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for tocilizumab injections provided from May 25, 2021, to July 20, 2021.  You asked the Plan to waive the coinsurance for the injections. You say that you were not billed for previous injections. 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 drugs.     Drug Allowed Amount 20% Coinsurance Tocilizumab - May 25, 2021 $1762.24 $352.45  $2202.80 $440.56 Tocilizumab - June 22, 2021 $660.84 $132.17  $1101.40 $220.28  $2202.80 $440.56 Tocilizumab - July 20, 2021 $4204.32 $840.86 Total:  $2426.88   You have been asked to pay $2426.88, which is 20% of the allowed amount for the injections. The injections fall 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 tocilizumab injections provided from May 25, 2021, to July 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group 3 power wheelchair represented by code K0856, and related accessories represented by codes E2361, E1002, E1012, E2311, E1028, E2620, E0955 and E2607.  You asked the Plan to pre-approve codes K0856, E2361, E1002, E1012, E2311, E1028, E2620, E0955 and E2607. You say that the records provided support the need for the requested items. The Plan denied your request. The Plan says the records do not show that the enrollee meets Medicare criteria for the requested power wheelchair and wheelchair options.  The Plan follows Medicare rules. Medicare rules say that power wheelchairs with a power tilt option are covered for certain medical indications and when medically necessary. Medicare rules say that related accessories will be denied when the power wheelchair base 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 codes K0856, E2361, E1002, E1012, E2311, E1028, E2620, E0955 and E2607. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee does not utilize bladder catherization, there is no documentation of muscle spasticity or increased tone, and there is no history of skin breakdown. The wheelchair being requested includes a power tilt option, but the records do not support that a wheelchair with this feature is medically necessary according to Medicare rules. Because the power wheelchair base is not covered, the related accessories are not considered medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes K0856, E2361, E1002, E1012, E2311, E1028, E2620, E0955 and E2607 have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair represented by code K0856, and related accessories represented by codes E2361, E1002, E1012, E2311, E1028, E2620, E0955 and E2607.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Trulicity injections.  You asked the Plan to pre-approve Trulicity injections. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Trulicity injections are not covered under the enrollee's Medicare Part B 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 Trulicity injections.   Benefits for Trulicity injections may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.