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

We decided that the Plan does not have to pre-approve Keytruda.

You asked the Plan to pre-approve Keytruda. You say that the requested Keytruda is medically necessary. The
Plan denied your request. The Plan says the requested Keytruda is not medically necessary.

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 Keytruda. Our reviewer says that the
requested Keytruda is not medically necessary. Our physician reviewer found the record indicates that the
enrollee has a diagnosis of mismatch repair deficient endometrial cancer. The record indicates that the
requested drug is being used as first line monotherapy. The Food and Drug Administration has not stated that
the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do
not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No
literature from Medicare approved cancer journals were submitted for review. The elements of the coverage
criteria 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 Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a porcelain crown (D2750) provided by a participating provider.

You asked the Plan to pay for a porcelain crown. You say that you would like the Plan to approve and pay for the requested crowns. The Plan denied your request. The Plan says the requested dental services are 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 a porcelain crown (D2750) provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and accessory (E0668).

You asked the Plan to pre-approve a pneumatic compression device. You say that this device is medically necessary to treat the enrollee's medical condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.

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 pre-approve a pneumatic compression device (E0652) and accessory (E0668).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Eliquis.

You asked the Plan to pre-approve self-administered drugs. You say that you are appealing this denial. 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 use of Eliquis.

Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a breast magnetic resonance imaging (MRI).

You asked the Plan to pre-approve an MRI. You say that mammogram procedures can cause old implants to rupture and the procedure caused you a lot of pain due to contracture and calcification of your implants. The Plan denied your request. The Plan says the medical criteria for the requested breast MRI has not been met.

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 an MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the enrollee no longer has silicone breast implants. Clinic notes from her provider in Family Medicine on 1/4/21 state that she has "saline breast implants that were placed in 1995; prior to that you had silicone implants." An MRI is not covered for suspected saline implant leaks.

In addition, her most recent mammogram from 1/15/21 also clearly documents that she has saline breast implants with no silicone found. In addition, her implants were placed for cosmetic reasons, so any leakage would be considered a complication of a non-covered service and so MRI would not be covered, even if the implants had been silicone. Finally, a mammogram would be considered the initial study for confirming leakage of a silicone implant and MRI would only be employed if this study was negative. She has not had a recent mammogram. The review has determined that the requested MRI is not medically reasonable or 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 an MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve a breast magnetic resonance imaging (MRI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a stair lift.  You asked the Plan to pre-approve a stair lift. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says the requested item is not a covered benefit.  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 pre-approve a stair lift.   Your complaint about receiving confusing or conflicting information about your benefits from representatives of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for mental health services provided from July 2, 2021, to July 12, 2021.

You asked the Plan to waive the copayments for mental health services. You say that you request that the claims be reprocessed. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 $95 copayment for mental health services provided in an outpatient hospital. 

You received mental health services at an outpatient hospital facility from July 2, 2021, to July 12, 2021, for a total of 4 visits. Therefore, you are responsible to pay a $95 copayment per each visit. The total amount you owe is: $95 (copayment) x 4 (mental health services) = $380.

You have been asked to pay the total copayment amount of $380 for mental health services. Mental health services fall within the outpatient hospital services 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 copayments for mental health services provided from July 2, 2021, to July 12, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ALS ambulance transport (A0433) and ground mileage (A0425) provided February 2, 2021.  You asked the Plan to pay for the ambulance service. You say that per the eligibility details, the Plan is the Medicare replacement policy and the claim had been paid correctly. Please review and reprocess.   The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition until the first day of the month following the month in which hospice was revoked or discharged.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on 02/03/2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the ALS ambulance transport (A0433) and ground mileage (A0425) provided February 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the seat lift mechanism and sales tax received on March 21, 2021.  

You asked the Plan to pay for the seat lift mechanism and sales tax. You say that you received a prescription from your physician and purchased the chair from a local vendor. The Plan denied your request. The Plan says the item is not a covered benefit when provided by a provider who is not under Medicare contract.  

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the seat lift mechanism and sales tax received on March 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy services (97110) provided on December 2, 2019.  

You asked the Plan to pay for physical therapy services. You say that this should be covered as in-network. The Plan denied your request. The Plan says this was not billed correctly.  

The Plan must follow Medicare rules. Medicare rules say that the services of Physical Therapy Assistants (PTAs) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.  

We looked at the file and Medicare rules. The services at issue were provided by a PTA billed as incident to a nurse practitioner's service. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services (97110) provided on December 2, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on April 23, 2021.  

You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the excessive charges and cannot afford them. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.  

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 $290 copayment for ambulance services.     

You have been asked to pay a $290 copayment for ambulance services. Ambulance services fall within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on April 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).  

You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your request. The Plan says this is being provided by a pharmacy.  

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.  

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).   

Benefits for Prolia 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 the eyeglasses (V2307, V2750, V2303) provided on March 17, 2021.

You asked the Plan to pay for the eyeglasses. You say that these services were necessary, and your previous eyewear needed to be replaced. The Plan denied your request. The Plan says the total cost of the eyewear purchased on March 17, 2021, was $429. The Plan has paid the full $350 annual allowance for routine eyewear, but the remaining cost exceeds the benefit allowance and is your responsibility.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan pays up to $350 every calendar year for supplemental routine eyewear. If the eyewear you purchase costs more than $350, you pay the difference. 

We looked at the file and the Plan's rules. Documentation shows that the eyewear purchased on the date in question exceeded the Plan's $350 benefit allowance. The Plan has paid the full allowance amount, and you are being asked to pay the difference. Based on this information, we decided that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay any additional amount for the eyeglasses (V2307, V2750, V2303) provided on March 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on May 21, 2021.  

You asked the Plan to waive the coinsurance for DME and related supplies. You say that the supplies used to be 100% covered and you are asking that they be fully covered again. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct amount.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for DME and related supplies.   

The enrollee received DME and related supplies on May 21, 2021. The total allowed amount is $429.60 and 20% of that is $85.92.  

The enrollee has been asked to pay the total coinsurance amount of $85.92 for DME and related supplies. DME and related supplies fall within the DME and related supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement of an implanted infusion pain pump.

You asked the Plan to pre-approve infusion pump. You say that pain pump replacement should be reconsidered since the estimated replacement date is less than 9 months away. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the estimated replacement date for this device is June 2022 and there is no documentation that the pump is not functioning well or has parts that need to be replaced.

The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical equipment can be no less than 5 years, and Medicare does not cover replacement of equipment within the reasonable useful lifetime. 

We looked at the file and Medicare rules. This equipment is still within its reasonable useful lifetime, so replacement is not covered at this time. Based on this information, we decided that Medicare rules for coverage of infusion pump have not been met. Therefore, we decided that the Plan does not have to pre-approve replacement of an implanted infusion pain pump.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the endovascular repair services coded 34846 provided on December 20, 2019.  You asked the Plan to pay for the endovascular repair services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.  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 34846 for the endovascular repair services is a column II code to column I code 34709. 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 endovascular repair services coded 34846 provided on December 20, 2019.
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. The Plan denied your request. The Plan says you do not require intensive therapy 3 hours a day.

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 physician reviewer found that you were admitted to the acute hospital with nausea and vomiting. You were diagnosed with acute encephalopathy and are medically stable. Functionally, you are at a minimal assist level for bed mobility, transfers, bathing and ambulation using a rolling walker.

You are at moderate assist for lower body dressing and total assist for toileting. With your current medical stability, and no other medical complexity, there is no need for rehabilitation physician supervision 3 times per week (at a minimum) for the management of active or acute exacerbations of chronic medical conditions. At the current functional level, you do not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. 

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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve out-of-network dental services.  

You asked the Plan to pre-approve out-of-network dental services. You say that you don't want to be shopping around for a new dentist in the middle of your care. You say that you want insurance to cover the costs with your current dentist until the treatment plan is completed. The Plan denied your request. The Plan says out-of-network dental 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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve out-of-network dental services.