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

We decided that the Plan does not have to pre-approve fifteen (15) boxes of BinaxNOW Coronavirus (COVID-19) at home testing kits.
You asked the Plan to pre-approve the kits. You say that daily COVID-19 testing is necessary based on other general symptoms and signs. The Plan denied your request. The Plan says COVID testing is provided at physician offices and approved COVID testing sites with payment/approval as outlined by the Evidence of Coverage.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the kits have not been met. The requested testing kits are available at retail stores without a physicians order and is therefore over the counter (eg, available at Walmart, Walgreens, CVS). Because this is over the counter available testing, it would not be covered under Medicare medical benefits. As an alternative, traditional COVID testing (PCR and antibody testing) remains available for Medicare benefit coverage with no
member cost share as outlined under the national public health emergency declaration and emergency directives from Centers for Medicare & Medicaid Services (CMS). Therefore, we decided that the Plan does not have to pre-approve fifteen (15) boxes of BinaxNOW Coronavirus (COVID-19) at home testing kits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Imfinzi, Paclitaxel, Carboplatin, Diphenhydramine HCL and Dexamethasone Sodium Phosphate for the enrollee.
You asked the Plan to pre-approve these drugs. You say that these drugs are medically necessary. The Plan denied your request. The Plan says that this is not being prescribed for a medically accepted indication.
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 these drugs. Our reviewer says that these drugs are not medically reasonable and necessary for the enrollee. These drugs are not FDA approved for the enrollee's condition. The use of these drugs is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these drugs.
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 drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Imfinzi, Paclitaxel, Carboplatin, Diphenhydramine HCL and Dexamethasone Sodium Phosphate for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the services are not necessary, and you can receive the care you need in another setting, such as home, a long-term care facility, or other outpatient setting.
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 have stabilized medically and have been discharged from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehabilitation services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a SNF. You do not have any parental medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near your baseline and you can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility.
You asked the Plan to pre-approve admission to a skilled nursing facility. You say that admission to a skilled nursing facility is medically necessary. The Plan denied your request. The Plan says there are insufficient records provided to show you required daily skilled nursing or daily skilled therapy services at an inpatient level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a skilled nursing facility when the four factors listed in the Medicare rules section are met. Custodial care is not covered. The records provided show you were treated for a bleeding ulcer. The records provided do not show you require skilled nursing or skilled therapy services daily at an inpatient facility level of care. Medicare coverage criteria are not met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. 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 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture after a fall and new onset atrial fibrillation. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the abdominal ultrasound you had on April 23, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that you would like a lower cost for this service or a refund. You said that this test was needed to determine the nature of your stomach issues. 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 $125 copayment for radiological diagnostic services. You have been asked to pay a $125 copayment for the ultrasound. The ultrasound falls within the radiological diagnostic services 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 the abdominal ultrasound you had on April 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve multiple repairs to the enrollee's power wheelchair.
You asked the Plan to pre-approve multiple repairs to the enrollee's power wheelchair. You say that you would
like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are
not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that for equipment to be covered, it must be
appropriate and needed for use inside the home.
We looked at the file and Medicare rules. The requested items should last a minimum of 24-90 months for
primary in-home mobility for completion of activities of daily living. The submitted documentation does not
support the need for the requested power wheelchair replacement parts due to the parts being rendered in
September 2020. Replacement due to wear is not covered during the reasonable useful lifetime of the
equipment. The documentation shows there to appears to be excessive wear and tear on the power mobility
device that was approved for primary use in the home and not as a community motor vehicle. Based on this
information, we decided that Medicare rules for coverage of multiple repairs to the enrollee's power wheelchair
have not been met. Therefore, we decided that the Plan does not have to pre-approve multiple repairs to the
enrollee's power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the fine needle aspiration biopsy procedure you had at an outpatient hospital facility on June 4, 2021.
You asked the Plan to waive the copayment for the biopsy. You say that when they took the specimen, they did not get enough, so you had to repeat the process a second time. You were charged two copayments and you don't feel as though you should have to pay the second copayment. 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 $225 copayment for outpatient surgery. You have been asked to pay a $225 copayment for the biopsy. The biopsy falls within the outpatient surgery
benefit category. This copayment applies regardless of the reason for the procedure. 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 fine needle aspiration biopsy procedure you had at an outpatient hospital facility on June 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex interspinous implant.
You asked the Plan to pre-approve Vertiflex interspinous implant. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 Vertiflex interspinous implant. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found you have chronic low back pain for two to five months and lumbar spinal
stenosis with neurogenic claudication. The record does not document efforts at conservative treatment. The
record indicates that imaging has demonstrated multiple level moderate to severe spinal stenosis. The record
does not indicate that you are indicated for operative treatment at more than two levels. Therefore, you do not
meet criteria for the requested 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 Vertiflex interspinous implant have not been met. Therefore, we decided that
the Plan does not have to pre-approve Vertiflex interspinous implant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture with a flexible base (D5226).
You asked the Plan to pre-approve the dental item. You say that this service is necessary. The Plan denied your request. The Plan says partial lower denture with flexible base 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 requested partial lower denture with flexible base is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture with a flexible base (D5226).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the scanning computerized ophthalmic
diagnostic imaging (SCODI) service you had on June 4, 2021.
You asked the Plan to waive the copayment for the SCODI service. You say that you had cataract surgery on
April 29, 2021, and this was a follow-up. You stated that because this service was related to your cataract
surgery, there should be no copayment. 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 $10
copayment for x-rays and ultrasounds.
You have been asked to pay a $10 copayment for the SCODI service. Medicare rules state that when you have
a surgery, certain services and included in the cost for the surgery itself and no additional cost sharing applies.
This is called the global surgical package. However, diagnostic tests and procedures are excluded from the
global surgical package, and separate cost sharing applies for these services even if related to surgery. The
SCODI service you received is a diagnostic test. The SCODI service falls within the x-rays and ultrasounds
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 the scanning computerized
ophthalmic diagnostic imaging (SCODI) service you had on June 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen concentrator.
You asked the Plan to pre-approve an oxygen concentrator. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says coverage criteria for home oxygen have not been met.
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 an oxygen concentrator. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that overnight oximetry on room air indicates hypoxemia for a total of about 12 minutes. However, the enrollee has a diagnosis of obstructive sleep apnea which can cause nocturnal hypoxemia. There is no indication in the medical records that the enrollee is being treated for sleep apnea. Medicare does not cover oxygen unless the hypoxemia persists during treatment of the sleep apnea, as with continuous positive airway pressure (CPAP). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the sleep apnea oral appliance you received on July 8, 2021.
You asked the Plan to waive the coinsurance for the sleep apnea oral appliance. You say that you are on a fixed income and cannot afford this coinsurance. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for durable medical equipment. You have been asked to pay 20% coinsurance for the sleep apnea oral appliance. The sleep apnea oral appliance falls within the durable 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 sleep apnea oral appliance you received on July 8, 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 the requested admission to an IRF is not medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.
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 complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary
rehabilitation program.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vision services with an out-of-network ophthalmologist.
You asked the Plan to pre-approve out-of-network vision services. You say that you have seen this provider in the past and would like to continue care as he knows about your hypertropia. The Plan denied your request. The Plan says radial keratotomy, LASIK surgery and other low vision aids are not covered under any condition.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve vision services with an out-of-network ophthalmologist.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for inpatient hospital services you received from April 30, 2021, to May 2, 2021.
You asked the Plan to reduce the copayment for the inpatient hospital services. You say that because you were admitted after midnight, you should only be responsible for one night's stay instead of two. 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 $295 copayment per day for days 1-6 for inpatient hospital services. The medical records confirm that you were officially admitted to the hospital on April 30, 2021 (as that is when the order to admit you was signed), and were discharged on May 2, 2021.
This confirms that you were an inpatient for two days. You have been asked to pay a copayment of $295 per day for two days, for a total of $590. 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 reduce the copayment for inpatient hospital services you received from April 30, 2021, to May 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on March 12, 2021, by a supplier not
enrolled in the Medicare program.
You asked the Plan to pay for foot orthotics. You say that you had understood that medical supplies were
covered under the Plan. The Plan denied your request. The Plan says rules for payment have not been met
because the supplier of the items at issue is not enrolled in the Medicare program.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on March 12,
2021, by a supplier not enrolled in the Medicare program.