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

We decided that the Plan does not have to pre-approve Vertiflex surgery.

You asked the Plan to pre-approve Vertiflex surgery. You say that the requested procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered experimental and 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 Vertiflex surgery. 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 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) supplies (K0553).

You asked the Plan to pre-approve the CGM supplies. You say that the item is medically necessary. The Plan denied your request. The Plan says you are not insulin treated with multiple daily administrations.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) supplies (K0553).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for ConfirmMDx testing provided on March 15, 2021.

You asked the Plan to pay for ConfirmMDx testing. You say that this test is covered by Medicare and was ordered subsequent to a biopsy. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing was not being considered for a second biopsy for persistent risk factors as required per Medicare guidelines.

The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx testing may be covered under certain conditions, including that the enrollee has undergone a previous cancer-negative prostate biopsy within 24 months and is being considered for a repeat biopsy due to persistent or elevated cancer-risk factors. 

We looked at the file and Medicare rules. The enrollee was not being considered for a repeat biopsy at this time this testing was ordered. Based on this information, we decided that Medicare rules for coverage of ConfirmMDx testing have not been met. Therefore, we decided that the Plan does not have to pay for ConfirmMDx testing provided on March 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve external counterpulsation therapy (G0166)

You asked the Plan to pre-approve external counterpulsation therapy. You say that this request is medically necessary for your condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan follows Medicare rules. Medicare rules say that external counterpulsation therapy is subject to the criteria listed 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 external counterpulsation therapy. Our reviewer says that the requested procedure is not medically reasonable and necessary. Our physician reviewer found although a recent stress test suggests possible silent ischemia, you have no angina or anginal equivalent symptoms reported and no activity limitations due to chest discomfort. You are not on an anti-anginal medications except "as needed" nitroglycerin either. In the absence of debilitating angina with class III or IV symptoms which are refractory to anti-anginal medical therapy, external counterpulsation therapy in this case would not meet the coverage criteria. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of external counterpulsation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve external counterpulsation therapy (G0166)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a Wellness Allowance for an annual health club membership provided in the 2020 benefit year.

You asked the Plan to reimburse you for a Wellness Allowance reimbursement. You say that the delay was due to you having some health issues. The Plan denied your request. The Plan says your reimbursement request for the 2020 benefit year was received on May 17, 2021, which was after the required March 31st deadline.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

The Plan's rules for coverage of gym benefits have not been met because your reimbursement request for the 2020 benefit year was received on May 17, 2021, which was after the required March 31st deadline. Therefore, we decided that the Plan does not have to reimburse you for a Wellness Allowance reimbursement for an annual health club membership provided in the 2020 benefit year.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on February 4, 2021.

You asked the Plan to pay for the testing services. You say that physicians send specimens for testing. The Plan denied your request. The Plan says the billed code cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

We looked at the file and the rules. The billed claim lists the place of service as an independent laboratory. The records do not indicate the specimen was obtained at an independent laboratory. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on February 4, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy with biopsy (45380) and
colonoscopy with lesion removal (45385) services provided on May 13, 2021.

You asked the Plan to waive the copayment for the colonoscopy services. You say that you expected to pay the
$0 copayment for a screening only. The Plan denied your request. The Plan says the colonoscopy provided
included a biopsy and removal of a lesion. Therefore, the $300 outpatient surgery copayment applies.

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 $300
copayment for outpatient surgery. A screening colonoscopy can become a diagnostic colonoscopy when the
screening colonoscopy results in the biopsy or removal of a lesion or growth, or when the biopsy or removal
happens during the same visit as the screening colonoscopy. You will be expected to pay the outpatient surgery
cost sharing when the colonoscopy is considered diagnostic.

You have been asked to pay a $300 copayment for the colonoscopy services. The colonoscopy services were
not billed as a screening and included a biopsy and lesion removal. 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 the colonoscopy with biopsy (45380) and colonoscopy with lesion removal (45385) services
provided on May 13, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 13 units of home INR testing (G0249).

You asked the Plan to pre-approve the INR testing. The Plan denied your request. The Plan says self-testing
with the device should not occur more frequently than once a week. The Plan also says that this service is not
medically 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 INR testing. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the record indicates that the enrollee has antiphospholipid antibody disorder. Our reviewer
found that the record indicates that the testing is ordered for every 5 to 7 days.

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 INR testing have not been met. Therefore, we decided that the Plan does not
have to pre-approve 13 units of home INR testing (G0249).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) (D0367), the pulp vitality test (D0460), and post removal (D2955) provided from April 22, 2021, to May 24, 2021.

You asked the Plan to pay for the dental services. You say that you were advised by a plan representative that this dentist was in network. You say that the office did not advise that the dentist did not accept Medicare. You also say that you should be reimbursed for these services. The Plan denied your request. The Plan says cone beam CT is not listed as a covered service. The Plan says that pulp vitality test is not listed as a covered service. The Plan also says that post removal is not listed as a covered service.

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 cone beam CT and pulp vitality test are not covered under the routine preventive dental benefit. The record shows that you were not enrolled in the optional supplemental dental benefit until May 2021. Additionally, the post removal is not under the optional supplemental dental benefit. Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) (D0367), the pulp vitality test (D0460), and post removal (D2955) provided from April 22, 2021, to May 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) receiver (K0554).

You asked the Plan to pre-approve a CGM receiver. You say that the item is medically necessary. The Plan denied your request. The Plan says you are only receiving/injecting insulin once a day at bedtime (not 3-4 times daily) and your insulin does not require frequent adjustment on the basis of your blood glucose results.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM receiver have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) receiver (K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a folding mobility scooter (K0899).

You asked the Plan to pre-approve a folding mobility scooter. You say that the item is medically necessary. The Plan denied your request. The Plan says equipment which serves as comfort, or convenience is considered non-medical in nature.

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 a folding mobility scooter (K0899).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and accessories (E0667).

You asked the Plan to pre-approve a pneumatic compression device and accessories. You say that a basic pump would not work for the enrollee. The Plan denied your request. The Plan says the enrollee has not had a trial with a basic pump.

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 accessories (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the life alert system.

You asked the Plan to pre-approve the life alert system. You say that the service is medically necessary. The Plan denied your request. The Plan says the requested service is not a covered benefit.

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 the life alert system.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Farxiga tablets.

You asked the Plan to pre-approve Farxiga tablets. You say that this is necessary to prevent hospitalization.
The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's
prescription drug plan.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Farxiga tablets.

Benefits for Farxiga tablets 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 waive the copayment for an ECG provided on May 27, 2021.

You asked the Plan to waive the copayment for an ECG. You say that you feel that the test should be included
as part of a pre-operative screening. 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 $50
copayment for outpatient diagnostic tests provided in a specialists office.

You received an ECG on May 27, 2021. ECG's are not included in pre-operative visits. Therefore, you are
responsible to pay the $50 copayment.

You have been asked to pay a $50 copayment for an ECG. An ECG falls within the outpatient diagnostic tests
and therapeutic services and supplies 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 an ECG provided on May 27, 2021.
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 the best option for this enrollee. The Plan denied your request. The Plan says the criteria for IRF care are not met.

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 enrollee is a female who was admitted to the hospital on 9/30/2021 due to right groin and abdominal pain after a recent abdominal aortic aneurysm (AAA) repair. The enrollee had blood loss anemia treated with transfusion and a urinary tract infection treated with antibiotics.

The enrollee does not meet coverage criteria for an IRF stay. At the current medical stability and lack of medical complexity, there is no need for physical medicine physician supervision 3 times per week for the ongoing management of any active or acute exacerbations of chronic medical conditions. Documentation does not support the need for therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with frequent physician oversight and an interdisciplinary approach to rehabilitation care. While she may benefit from further therapies, the enrollee's therapy needs can be addressed at a lower intensity level. 

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 you were admitted with acute hypoxic respiratory failure from Coronavirus infection. The record indicates that you remain critically ill on high flow oxygen. You continue to receive acute care services, and these have not been denied. The medical record does not indicate that you require services that you are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.

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 you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that you will not 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.