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

We decided that the Plan does not have to pre-approve brain imaging, minimum 4 static views (CPT code
78605), for the enrollee.

You asked the Plan to pre-approve the imaging. You say that functional brain imaging is warranted to help with
the right diagnosis and hence, guide the right treatment for this enrollee. The Plan denied your request. The
Plan says the enrollee's records do not show that the cause of their symptoms remains unclear after the
enrollee's doctor assessed the enrollee for other known cases of the enrollee's type of problem.

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 imaging. Our physician reviewer
found the enrollee does not currently meet diagnostic criteria for both AD and FTD. While the enrollee has
features of certain conditions the records and not sufficient to say that the enrollee would meet diagnostic
criteria for both. Furthermore, it was not otherwise noted that other etiologies that could contribute to cognitive
changes had otherwise been fully evaluated and accounted for. In such a setting the criteria for coverage cannot
be considered to have been met.

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 imaging have not been met. Therefore, we decided that the Plan does not
have to pre-approve brain imaging, minimum 4 static views (CPT code 78605), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
You asked the Plan to pre-approve the monitor. You say that coverage should be reconsidered. The Plan denied your request. The Plan says this is available over the counter.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an orthopedic evaluation to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are available in-network.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an orthopedic evaluation to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical and occupational therapy visits.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is no clear need for the requested services.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
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 services. Our physician reviewer found that in this case, the documentation does not support that the enrollee requires additional skilled rehabilitation services to provide treatment that is medically necessary. She does not require additional skilled services to effectively provide treatment in order to improve the enrollee's condition or perform a maintenance program to maintain her condition or prevent deterioration. She has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Therefore, the requested home health services are 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health physical and occupational therapy visits
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 services are medically necessary. The Plan
denied your request. The Plan says coverage criteria has not been 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 patient does 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 this patient 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve light compression bandages (A6448, A6449, A6450), a padding bandage (A6441), a self-adherent bandage (A6445), and a conforming bandage (A6443).

You asked the Plan to pre-approve light compression bandages, a padding bandage, a self-adherent bandage, and a conforming bandage. You say that you need this to treat your lymphedema. The Plan denied your request. The Plan says these items are only covered for qualifying wounds.

The Plan must follow Medicare rules. Medicare rules say that claims for compression bandages and multi-layer systems used without a qualifying wound or when used for other non-qualifying conditions will be denied as statutorily non-covered, no benefit.

We looked at the file and Medicare rules. The records do not show that you have a qualifying wound. Based on this information, we decided that Medicare rules for coverage of light compression bandages, a padding bandage, a self-adherent bandage, and a conforming bandage have not been met. Therefore, we decided that the Plan does not have to pre-approve light compression bandages (A6448, A6449, A6450), a padding bandage (A6441), a self-adherent bandage (A6445), and a conforming bandage (A6443).
Appeal type: Surgery
Decision: Unfavorable

Explanation of decision
We decided that the Plan does not have to pre-approve breast reduction (CPT code 19318).
You asked the Plan to pre-approve the surgery. You say that one side was approved and not the other. You state you are in need of the other side as you are in pain. The Plan denied your request. The Plan says your request is not medically necessary under Medicare rules because you are not having signs or symptoms from the enlarged breast and you did not have surgery to this breast for cancer removal. The Plan states you are trying to achieve symmetry to the breasts for aesthetic purposes.
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 surgery. Our physician reviewer found cosmetic surgery to reshape the breasts to improve appearance is not a Medicare benefit. Reduction Mammoplasty may be covered to reduce the size of a normal breast to bring it into symmetry with a breast reconstructed after cancer surgery. You have not had cancer surgery. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve breast reduction (CPT code 19318).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for routine eyewear provided on May 25, 2021.

You asked the Plan to pay for eyewear. You say that you believe that this charge is incorrect. The Plan denied your request. The Plan says the denial of additional payment for this eyewear is correct, because the Plan has paid the full $150 eyewear allowance and you are responsible for any costs above this amount.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to a $150 allowance every year. 

We looked at the file and the Plan's rules. The Plan has paid the full $150 allowance for supplemental eyewear for this year; therefore, you are responsible for all costs over this amount. Based on this information, we decided that the Plan's rules for coverage of eyewear have not been met. Therefore, we decided that the Plan does not have to pay for routine eyewear provided on May 25, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you will not be able to gain the services needed from a home health agency. The Plan denied your request. The Plan says you do not need skilled nursing or rehabilitation services.
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 services. Our physician reviewer found that you were admitted to the acute care hospital with abdominal pain. You have a stage IV pressure ulcer of the ischium that is chronic in nature. You have been treated for a urinary tract infection and acute sacral osteomyelitis. You are medically stable without any acute exacerbations of chronic medical problems. The most recent therapy documentation indicates you continue to be non-ambulatory. Your physical function is at or near your baseline. Although further rehab services would be appropriate to improve function, you do not require skilled nursing or skilled therapy services 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power seat elevation (E2300), pouch and transfer handles (K0108).
You asked the Plan to pre-approve the power seat elevation, pouch and transfer handles. You say that you would like reconsideration because the requested equipment is medically necessary. The Plan denied your request. The Plan says the the power seat elevation, pouch and transfer handles are not primarily 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 the power seat elevation (E2300), pouch and transfer handles (K0108).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the SNF services. You say that the services are medically necessary. The
Plan denied your request. The Plan says 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 the SNF services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found daily skilled services are not shown
to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The
enrollee's care needs can be provided at a lower level of care.

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 services have not been met. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

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 step therapy requirement is not met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has age-related osteoporosis without current pathological fracture. She has not tried and failed the Plan's required drug, intravenous (IV) bisphosphonates. The records do not show that the required drug would be contraindicated or less effective; therefore, Prolia is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide twelve additional routine transportation trips for the current year.

You asked the Plan to provide additional routine transportation. You say that you need additional transportation to get to your appointments. The Plan denied your request. The Plan says transportation beyond the 48 trips covered by your routine transportation benefit are not covered.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide twelve additional routine transportation trips for the current year.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the back brace provided on May 15, 2021.
You asked the Plan to waive the coinsurance for the back brace. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a back brace on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan.
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 20% coinsurance for Durable medical equipment. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a back brace on May 15, 2021. You have been asked to pay a 20% coinsurance for the back brace, totaling $191.04. The back rable medical equipment 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 coinsurance for the back brace provided on May 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation hospital services you received from May 5, 2021, to May 22, 2021.

You asked the Plan to waive the copayment for the inpatient rehabilitation hospital services. You say that you are on a fixed income and you were not expecting this bill. The Plan denied your request. The Plan says you were charged this copayment correctly.

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 $325 copayment per day for days 1-5, and a $0 copayment per day for additional days for inpatient hospital care (including inpatient rehabilitation).

You have been asked to pay a $325 copayment per day for days 1-5, and a $0 copayment per day for the additional days. 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 inpatient rehabilitation hospital services you received from May 5, 2021, to May 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable home ventilator.

You asked the Plan to pre-approve a portable home ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says that use of a portable ventilator to deliver ventilatory support via settings that could be equally provided by a BiPAP with average volume-assured pressure support settings is unnecessary.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 portable home ventilator. Our reviewer says that a portable home ventilator is not medically reasonable and necessary. You have had no recent hospitalizations. You have been evaluated with spirometry which suggested COPD. There are no results of full pulmonary function studies or arterial blood gases. There is no evidence of use of positive airway pressure. The review indicates that you do not have neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure consequent to chronic obstructive pulmonary disease. Our physician reviewer found that your condition does not meet Medicare criteria for a portable home ventilator. 

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 portable home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on May 4, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services (97810) rendered by the out-of-network (OON) provider from March 30, 2021, through April 30, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 the acupuncture services (97810) rendered by the out-of-network (OON) provider from March 30, 2021, through April 30, 2021.