Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses provided on September 10, 2021.
You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. The Plan says authorization rules apply for out-of-network covered supplemental vision services.
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 an authorization was not obtained for the eyeglasses. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided on September 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve transport ready option equipment.  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. 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 transport ready option equipment.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection rendered on September 6, 2021.  You asked the Plan to pay for 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. Medicare rules say that for code 62320 to be covered, certain documentation requirements must be met.        The medical records in this case do not meet Medicare's documentation requirements.  Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for the injection rendered on September 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve MyoPro Motion G (L8702)  You asked the Plan to pre-approve MyoPro Motion G. You say that this device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested device is 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 MyoPro Motion G. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. The requested item is not medically reasonable and 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 MyoPro Motion G have not been met. Therefore, we decided that the Plan does not have to pre-approve MyoPro Motion G (L8702)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Volara-oscillation lung expansion device (E1399).  You asked the Plan to pre-approve a HFCWOD. You say that given the therapies tried and failed, the Volara is a great alternative and medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the criteria for medical necessity for the requested device.  The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.   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 a HFCWOD. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of COPD and chronic atelectasis requiring frequent airway clearance. He is using bronchodilators. Records did not clearly show that the patient had tried and failed a standard airway clearance device. Based on the provided records, the enrollee does have bronchiectasis for which a high frequency chest wall oscillation device may be covered. The enrollee does not presently use a mechanical in-exsufflation device (E0482) and plan to continue to do so. The records do not show well-documented failure of standard treatments to adequately mobilize retained secretions.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a HFCWOD have not been met. Therefore, we decided that the Plan does not have to pre-approve Volara-oscillation lung expansion device (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that you are in support of the discharge disposition plan for long-term acute care. The Plan denied your request. The Plan says the care can be safely received in another setting, such as a skilled nursing or at home with home health services, once the enrollee is ready to leave the hospital.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that care at the skilled nursing facility level is not appropriate when the enrollee is otherwise stable for hospital discharge. The enrollee has a PICC line for intravenous antibiotics and his wound appears to be stable for hospital discharge with continued local wound care and the vacuum device. He is otherwise on outpatient medications and appears to be appropriate for care in skilled nursing facility when otherwise stable for hospital discharge.
The short-term acute care hospital can provide for all of the patient's present inpatient care needs and the enrollee is receiving an appropriate level of care in the present 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Stiolto Respimat inhaler.
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 self-administered drugs are not covered.
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 a Stiolto Respimat inhaler.
Benefits for these services 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: Unfavorable

 We decided that the Plan does not have to pre-approve Keytruda.  You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says the enrollee has not had a repeat biopsy or plasma testing.  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 physician reviewer found that the enrollee has stage IV non-small cell lung cancer. The requested use of Keytruda is not FDA-approved for the enrollee's diagnosis as there has been no PDL1 testing. The requested use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee.  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 pre-approve maxillary partial denture - cast metal framework with resin denture bases (CPT code D5213).
You asked the Plan to pre-approve the dental services. You say that the partial that was made can no longer be used as the tooth that it hooked onto has broken off down to the gum line and the remainder had to be surgically removed. The Plan denied your request. The Plan says you exhausted your benefit frequency limit. The Plan states you were last seen at the office on October 27, 2021, for an exam and you were given a referral to see a prosthodontist to assist with your dentures. The Plan states they encourage you to call a prosthodontist within your network plan to address any concerns and schedule an appointment for assistance.
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.
Records indicate you received this service on September 20, 2019. According to your 2022 EOC, your benefit provides coverage for dentures and partial dentures once every five years. Therefore, your benefits have been exhausted for the 2022 plan year. Therefore, we decided that the Plan does not have to pre-approve maxillary partial denture - cast metal framework with resin denture bases (CPT code D5213).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xiidra 5% drops.  You asked the Plan to pre-approve Xiidra. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says drug coverage is limited only to those drugs covered under the Plan'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 Xiidra 5% drops.   Benefits for Xiidra may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the IRF will get the enrollee back to his functional status. A lower level of care will not help him to live independently. You say that the enrollee meets the criteria. The Plan denied your request. The Plan says the denial of authorization for the IRF service is correct.  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 the medical record shows the enrollee's condition is stable. While the enrollee 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 the 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for facility services (99053) provided on May 19, 2021.  You asked the Plan to pay for facility services. You say that this was billed correctly. The Plan denied your request. The Plan says this is not separately payable.  The Plan must follow Medicare rules. Medicare rules say that a Medicare Physician Fee Schedule Database (MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment for other services not specified.  We looked at the file and Medicare rules. Code 99053 has a status indicator of B and is not separately payable. Based on this information, we decided that Medicare rules for coverage of facility services have not been met. Therefore, we decided that the Plan does not have to pay for facility services (99053) provided on May 19, 2021.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pay for the excision of a benign tumor and bone graft (21047, 21215) provided on May 25, 2021.  You asked the Plan to pay for the excision of a benign tumor and bone graft.. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the claim history indicates that global payment for this code has already being processed to another provider.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not forwarded any evidence that these services were paid to another provider. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the excision of a benign tumor and bone graft (21047, 21215) provided on May 25, 2021.   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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (62320) provided on October 11, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the required clinical records were not submitted.
The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing the care to the patient. In addition, the procedure report should clearly document the indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved immediately post-injection.
The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record
is not signed and there is no notation of the percent of pain relief achieved either before or after the injection.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay
for the services (62320) provided on October 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group 1 power operated vehicle (K0800).  You asked the Plan to pre-approve a group 1 power operated vehicle. You say that this item is medically necessary for you to go out shopping. The Plan denied your request. The Plan says this item is not 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 group 1 power operated vehicle (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (62320) provided on September 20, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the required clinical 
records were not submitted.
The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain 
documentation requirements must be met. The documentation must include the legible signature of the 
physician or non-physician practitioner responsible for providing the care to the patient. In addition, the 
procedure report should clearly document the indications and the medical necessity for the blocks along with 
the pre and post percent pain relief achieved immediately post-injection.
The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record 
is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay 
for the services (62320) provided on September 20, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the home infusion services (62369, 99601) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the home infusion services. You say that it is necessary for an OON provider to provide this medical care. The Plan denied your request. The Plan says there are in-network options that the enrollee can use.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the home infusion services (62369, 99601) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for pain management services (procedure code 62320) provided to the enrollee on August 16, 2021.  You asked the Plan to pay for the services. You say that the services were billed correctly and should be paid for. The Plan denied your request. The Plan says the records are insufficient to support payment for the services.  The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing the care to the patient.   In addition, the procedure report should clearly document the indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved immediately post-injection.  The medical records in this case do not meet Medicare's documentation requirements.  Specifically, there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. 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 pain management services (procedure code 62320) provided to the enrollee on August 16, 2021.