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

 We decided that the Plan does not have to pay for reprogramming and diagnostic analysis of cochlear implants (92604) provided on April 2, 2021.  You asked the Plan to pay for diagnostic analysis of cochlear implants. You say that these services were necessary. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids and routine hearing exams performed by providers in the Plan's routine hearing vendor network.   We looked at the file, Medicare rules and the Plan's rules. The service in question is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for reprogramming and diagnostic analysis of cochlear implants (92604) provided on April 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric services.  You asked the Plan to pre-approve inpatient psychiatric services. You say that the medical records provided support the need for inpatient psychiatric care. The Plan denied your request. The Plan says the enrollee no longer meets the criteria for this level of care. The Plan says that there are less restrictive levels of care that would be appropriate.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.    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 inpatient psychiatric services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. The enrollee was cooperative and compliant with medication. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a multiaxial rotation unit and shank foot system.  You asked the Plan to pre-approve a multiaxial rotation unit and shank foot system. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that an axial rotation unit (L5982, L5984, L5985, L5986) is covered for beneficiaries whose functional level is 2 or above.  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 multiaxial rotation unit and shank foot system. Our reviewer says that the items are not medically necessary. Our physician reviewer found the physician documentation does not support that the enrollee's functional level and activities are a K3 level and require an advanced foot. The request exceeds the enrollee's medical need and is not 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 a multiaxial rotation unit and shank foot system have not been met. Therefore, we decided that the Plan does not have to pre-approve a multiaxial rotation unit and shank foot system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hearing aids provided on January 7, 2021.  You asked the Plan to pay for the hearing aids. You say that you were under the impression that you did not need to go to a contracting provider for this. You say that the brochure is misleading, and you should be accommodated. The Plan denied your request. The Plan says hearing aids must be purchased through the Plan's hearing aid vendor.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are purchased from the Plan's hearing aid vendor.     We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Specifically, the hearing aids were not purchased from the Plan's hearing aid vendor. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on January 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says there are not complicated wounds or multiple complicated medications which cannot be given in the current location.
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 physician reviewer found that the enrollee was admitted to the current acute care hospital with Vancomycin-resistant enterococci (VRE) bacteremia due to infected decubitus ulcer, nausea/vomiting, and DVT. The enrollee's care was complicated requiring mechanical ventilation, liver failure, malnutrition requiring enteral feeding, and anemia requiring transfusion. She was extubated and placed on high flow oxygen. She is currently requiring additional IV antibiotics, physical therapy in time, high flow oxygen, tube feeds, and telemetry monitoring. The enrollee appears to still require acute care services for at least the short term, and has been improving at a rate that acute care services will likely not be needed for more than 24 days. Weaning down on oxygen, monitoring, antibiotics and eventually physical therapy can be managed at the current setting. The enrollee does not require services at the proposed LTACH that are not already available at the current facility. Therefore, this request for LTACH services will be considered not 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the walker purchased on January 14, 2020 from an out of network (OON) provider.
You asked the Plan to pay for the walker. You say that you bought the walker because you couldn't walk. You could not walk without the walker. Please reconsider. You needed it. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. Non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 has network providers available who can provide 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 the walker purchased on January 14, 2020 from an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for an inpatient admission provided from June 16, 2021, through June 25, 2021.  You asked the Plan to pay for an inpatient admission. You say that the inpatient admission was medically necessary. The Plan denied your request. The Plan says no authorization was obtained.  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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an inpatient admission provided from June 16, 2021, through June 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for  the pneumatic compression device (E067 and E0673), provided on July 8, 2021.  You asked the Plan to pay for  a pneumatic compression device. You say that you need these items. The Plan denied your request. The Plan says DME must be used in the home and is not a covered item.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  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, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for  the pneumatic compression device (E067 and E0673), provided on July 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.  You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.  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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Aduhelm.  You asked the Plan to pre-approve Aduhelm. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.   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 Aduhelm. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. 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 Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm.
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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  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 based on the medical records provided this enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis if needed appear appropriate in this case.  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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on May 8, 2021.  You asked the Plan to pay for ambulance response and treatment, no transport. You say that with your heart history you called 911 as a precaution as you live alone and did not feel you could drive to the emergency room safely. You say that the EMT's arrived and performed an EKG and they told you that your heart was okay. You say that you should not have to pay for this service because if it had been your heart and you had not called 911, you could have died. The Plan denied your request. The Plan says your Plan covers ambulance transportation only when you are actually transported by ambulance. Since you were not transported by this ambulance, the service is not covered under your Plan.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on May 8, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on May 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on May 20, 2021.  You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says there are no authenticated medical records from the ordering provider.  The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed.   We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on May 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided on June 30, 2021.  You asked the Plan to pay for the self-administered drugs. You say that the eye drops were administered by a staff member and were a necessary part of the laser surgery. The Plan denied your request. The Plan says self-administered drugs are not covered by Medicare.  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 pay for the self-administered drugs provided on June 30, 2021.   Benefits for the 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve tumor treatment field therapy (TTFT).  You asked the Plan to pre-approve TTFT. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that tumor treatment field therapy (E0766) will be denied as not reasonable and necessary for the treatment of recurrent GBM.  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 TTFT. Our reviewer says that the services are not medically necessary. Our physician reviewer found records indicate the enrollee has a Karnofsky Performance Score (KPS) of 40; LCD criteria require a KPS of at least 70. In addition, the LCD states that Tumor Treatment Field Therapy will be denied as not reasonable and necessary for the treatment of recurrent glioblastoma multiforme.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of TTFT have not been met. Therefore, we decided that the Plan does not have to pre-approve tumor treatment field therapy (TTFT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and bitewing x-ray (D0270) provided on August 9, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation and bitewing x-ray. You say that the first dentist recommended you go to an orthodontist. You also say that the orthodontist had to take their own x-rays because they could not locate the problem from the initial dentist's x-rays. The Plan denied your request. The Plan says the frequencies for these procedures have been exceeded.  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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on April 21, 2021 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. The Plan contract also says that bitewing x-rays (D0270, D0272, D0273, D0274, D0277) are limited to one procedure per plan year. The record shows that you received bitewing x-rays (D0274) on July 29, 2021 and your bitewing x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and bitewing x-ray (D0270) provided on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on October 16, 2020.  You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99153 may not be paid if furnished to a hospital inpatients or patients in a hospital outpatient department.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.   We find that CPT code 99153 is not supported in the record. Specifically, CPT code 99153 has a Professional/Technical Component Indicator of 3 meaning this is a technical component only code. Payment for the technical component is included in the payment to the facility and is not separately reimbursable.  Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153) provided on October 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the crown and nitrous oxide provided on July 2, 2021.  You asked the Plan to pay for the crown and nitrous oxide. You say that a crown was the only option in seeking the necessary relief. You say that the crown became a necessity not a luxury and insurance covers these items. The Plan denied your request. The Plan says the services are not covered benefits.  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 the crown and nitrous oxide provided on July 2, 2021.