Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (43239) provided on October 1, 2021.  You asked the Plan to waive the copayment for the esophagogastroduodenoscopy. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 $375 copayment for Outpatient diagnostic tests and therapeutic services and supplies.        You have been asked to pay a $375 copayment for an esophagogastroduodenoscopy. Esophagogastroduodenoscopies fall 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 esophagogastroduodenoscopy (43239) provided on October 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve carboplatin, pembrolizumab, and pemetrexed
combination therapy.
You asked the Plan to pre-approve the requested combination therapy. You say that it is felt that this
progression occurred after chemotherapy was stopped and that adding carboplatin back would be beneficial.
The Plan denied your request. The Plan says since there was progression of disease on these drugs, they can no
longer be considered effective.
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 the requested combination therapy. Our
reviewer says that the requested regimen is not considered medically reasonable and necessary at this time. Our
physician reviewer found the enrollee suffers from metastatic non-small cell lung cancer. The requested
regimen is approved as first-line therapy, but the enrollee has had two prior lines of therapy. There is no
support for this regimen in the enrollee's situation in the major drug compendia or approved medical journals. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the requested combination therapy have not been met. Therefore, we decided
that the Plan does not have to pre-approve carboplatin, pembrolizumab, and pemetrexed combination therapy.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung
cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. You say that this is medically necessary. The
Plan denied your request. The Plan says the request cannot be approved.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter. We reviewed the file and the Medicare rules. We find that you outside of the age range of 55-77 years old..
Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT)
scan for lung cancer screening.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 17, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says screening services are not a Medicare covered
benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare
does not cover this test solely for screening purposes. Additionally, the documentation submitted does not
include a lab report, physician order or medical records. There is insufficient information to determine why this
testing was ordered, how it was affect the member's treatment and if Medicare criteria for coverage have been
met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on
July 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz injections for the left knee.
You asked the Plan to pre-approve the Supartz injections. You say that the enrollee has benefited from this
treatment on the right knee and should be covered for left knee injections as well. The Plan denied your
request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that viscosupplementation injections may be covered
when the enrollee has knee pain that has persisted despite three months of conservative measures.
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 Supartz injections. Our reviewer
says that the requested procedure is not medically necessary at this time. Our physician reviewer found there is
no documentation of a recent trial and failure of conservative measures to include 6 weeks of physical therapy
for left knee pain. 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 Supartz injections have not been met. Therefore, we decided that the Plan
does not have to pre-approve Supartz injections for the left knee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular artery embolization.
You asked the Plan to pre-approve the requested genicular artery embolization. You say that this is a
reasonable treatment that can reduce the need for medications. The Plan denied your request. The Plan says
there is no support in the literature for this procedure.
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 requested genicular artery
embolization. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found the requested procedure is experimental for the treatment
of knee pain. More research is needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the requested genicular artery embolization have not been met. Therefore, we
decided that the Plan does not have to pre-approve genicular artery embolization.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from September 25, 2020, to September 27, 2020.  You asked the Plan to pay for the self-administered drugs. You say that you received a bill for $348.90. You say that it is for self-administered drugs that you received while you were at the hospital. You say that you did not do any self-administered drugs. You also say that the hospital provided everything that you needed. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.  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 in an outpatient setting from September 25, 2020, to September 27, 2020.   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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer.
You asked the Plan to pre-approve the Superion procedure. You say that this treatment is proven effective and
should be covered. The Plan denied your request. The Plan says there is not sufficient support in the literature
for this procedure.
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 Superion procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Superion spacer is experimental for back pain. 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 Superion procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve placement of the Superion interspinous spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued mental health treatment in an intensive
outpatient program (IOP).
You asked the Plan to pre-approve the IOP treatment. You say that the enrollee has been approved for the first
week of treatment but needs to complete the 8-week program. The Plan denied your request. The Plan says the
enrollee's needs can be met at a lower level of care.
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 IOP treatment. Our reviewer says
that the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found This patient is being treated for Schizoaffective Disorder Bipolar Type and Cannabis Use
Disorder in Remission. Based on review the records provided for the dates in question, the patient does not
have any suicidal or homicidal ideation and did not have any auditory/visual hallucinations or psychosis. He
did not have any medical issues requiring the intensive outpatient level of care. There was no report of this
patient requiring assistance with daily living activities. The patient was cooperative with care while being
involved in his treatment and as well as participating in his treatment plan and attending groups. Based on the information provided in the record, this patient does not meet criteria for intensive outpatient
mental health treatment as this patient was not a danger to himself or others, did not have auditory or visual
hallucinations and was able to care for himself, but could be treated in a lesser restrictive environment
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 IOP treatment have not been met. Therefore, we decided that the Plan does
not have to pre-approve continued mental health treatment in an intensive outpatient program (IOP).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and complete
series x-ray (D0210) provided on March 19, 2021.
You asked the Plan to pay for the dental services. You say that you consulted with the plan before you went to
the dentist. You say that the provider did not perform the required procedure. You say that you had to go see a
specialist instead. You also say that you should not have been charged for this. The Plan denied your request.
The Plan says 1 oral exam is covered every 6 months. The Plan says that 1 complete series x-ray is covered
every 36 months. The Plan also says that these frequency limits 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 and the services are covered, the
frequency limits have been exceeded. The record shows that the Plan paid for an oral exam that you received
on March 12, 2021, and a complete series x-ray that you received on August 20, 2020. Therefore, we decided
that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and complete series x-ray
(D0210) provided on March 19, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable wheelchair controller (E2377), with
related electronic connections (E2311) and harness (E2313).
You asked the Plan to pre-approve the expandable controller with related hardware. You say that it is felt that
the requested components are needed The Plan denied your request. The Plan says all other components are
approved; however, the expandable controller 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 expandable controller with related
hardware. Our reviewer says that the requested items are not considered medically reasonable and necessary in
this case. Our physician reviewer found although there are three approved power options on this wheelchair
(tilt, recline and elevating leg rests), there is not a medical need to control these power options through the
joystick. The member's wife and caregivers can control the options through the approved attendant control or
through the switches provided with the power options. The review has determined that the items at issue in this
case are 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 the expandable controller with related hardware have not been met. Therefore,
we decided that the Plan does not have to pre-approve an expandable wheelchair controller (E2377), with
related electronic connections (E2311) and harness (E2313).
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 requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.  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 the enrollee received oral medications. The enrollee had stable vital signs and his lungs were clear. The enrollee was independent to stand by assist level with functional mobility including gait to 150 feet. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: 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 requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you received oral medications and had stable vital signs. You tolerated a mechanical soft diet and thin liquids, and your lungs were clear. You were at a supervision/stand by assist level with functional mobility including gait to 75 feet with a rolling walker. You do not require skilled nursing or therapy services on a daily basis and do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: 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 requested admission to a SNF is medically
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet
criteria.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you received oral medications and a
gastrostomy tube. You had stable vital signs and routine tracheostomy care. You were at stand by assist to
contact guard assist level for functional mobility and tolerated an oral diet. You do not require skilled nursing
or therapy services on a daily basis and do not meet severity of illness or intensity of service criteria for an
inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that you feel that more therapy is needed in
order to regain strength. The Plan denied your request. The Plan says remaining needs are custodial in nature.
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 the SNF admission. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee presented to acute care
on 2/14/2022 due to shortness of breath and leg swelling. She was treated in the hospital with cardiology
consultation, intravenous diuretics, and supplemental oxygen for a heart failure exacerbation and improved.
She has been evaluated by physical and occupational therapy in the hospital. She is reported to be wheelchair
bound at baseline and in need of assistance in her assisted living facility. As of 02/21/2022 she required
moderate assistance for transfers and minimum assist for grooming; no other details with regard to needs with
activities of daily living are provided. She is reported to be medically stable for discharge on outpatient
medications including oral torsemide.
The specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and
effectively provide medically necessary and reasonable treatment. The medical records provided do show that
this patient does require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a
qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment.
However, these services are not required on a daily basis.
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 SNF admission have not been met. Therefore, we decided that the Plan does
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral exam (D0120) provided on September 23,
2021.
You asked the Plan to pay for the dental service. You say that you had a routine cleaning done. You also say
that this should be covered. The Plan denied your request. The Plan says 2 periodic or comprehensive oral
exams are covered per calendar year. The contract also says the frequency limit has 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 and periodic oral exam is listed as
covered, the frequency limit has been exceeded. The record shows that the Plan paid for a periodic oral exam
that you received on March 11, 2021, and a comprehensive oral evaluation that you received on September 15,
2021. Therefore, we decided that the Plan does not have to pay for the periodic oral exam (D0120) provided on
September 23, 2021.