Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle libre 14-day sensor.

You asked the Plan to pre-approve a Freestyle libre 14-day sensor. You say that the item is 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. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle
libre 14-day sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a
Freestyle libre 14-day sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) and the laboratory service (81003) rendered by the out of network (OON) provider on September 10, 2020.

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 office visit (99214) and the laboratory service (81003) rendered by the out of network (OON) provider on September 10, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home visit for assistance with activities of daily living and personal care and nursing care in the home.

You asked the Plan to pre-approve a home visit for assistance with activities of daily living and personal care. You say you need a home visit for assistance with activities of daily living and personal care The Plan denied your request. The Plan says these services are not medically necessary.

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 a home visit for assistance with activities of daily living and personal care. Our reviewer says that a home visit for assistance with activities of daily living and personal care is not medically necessary. Our physician reviewer found that based on the documentation provided, the health Plan's denial should be upheld. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. As such, home health services including associated home health aide services are not shown to be medically necessary or reasonable. 

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 home visit for assistance with activities of daily living and personal care have not been met. Therefore, we decided that the Plan does not have to pre-approve a home visit for assistance with activities of daily living and personal care.
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. You say that LTACH admission is medically necessary. The Plan denied your request. The Plan says the enrollee is currently at the appropriate level of care.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. 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 he 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 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 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 pre-approve a Dexcom G6 continuous glucose monitor (CGM).

You asked the Plan to pre-approve a Dexcom G6 CGM. You say that the item is necessary. The Plan denied your request. The Plan says the enrollee has a fully functioning CGM which is still under warranty. Therefore, coverage criteria have not been met.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The file shows that the enrollee has a FreeStyle Libre. A FreeStyle Libre serves the same purpose as a Dexcom G6 CGM. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided on March 10, 2021.

You asked the Plan to pay for the comprehensive exam. You say that this benefit limitation is not explained anywhere in your benefits package. The Plan denied your request. The Plan says they paid for a previous comprehensive oral evaluation less than three years ago. Because this service can only be covered once every three years, payment cannot be made.

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. The Plan's contract states that the Plan can cover one periodontal or comprehensive oral evaluation every three years. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the comprehensive exam is requested in a frequency that is not covered under this benefit. Documentation shows that you had a previous comprehensive evaluation in June of 2019, which is less than three years before the date in question. Therefore, we decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided on March 10, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for Prolaris genetic testing provided on January 5, 2021.

You asked the Plan to pay for Prolaris testing. You say that the Plan is required to pay this claim and you are the only laboratory that performs this testing. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because the Plan considers this testing to be investigational.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. 

This testing was ordered by an in-network provider. The file does not show that the plan provided notice that Prolaris testing would not be covered. Under Medicare rules, this means Prolaris testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for Prolaris genetic testing provided on January 5, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Opdivo.

You asked the Plan to pre-approve Opdivo. You say that the enrollee was not interested in chemotherapy as a treatment, so you are offering this option of Opdivo. The Plan denied your request. The Plan says the denial of authorization for Opdivo is correct, because the information provided does not establish medical necessity.

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 Opdivo. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of Opdivo. Our physician reviewer found the requested use of Opdivo is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. The enrollee has had no prior systemic therapy and is not planned to use ipilimumab. In addition there is no PD-L1 or driver mutation reported. The requested use of Opdivo is not supported by major drug compendia or by clinical research appearing in a Medicare-approved medical journal.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Opdivo.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for direct skilled nursing services of a registered nurse (RN) in a
home health setting (G0299).

You asked the Plan to pay for the skilled nursing services. You say that these services are medically necessary.
The Plan denied your request. The Plan says the skilled nursing services are not necessary, as you do not have
skilled nursing needs.

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 pay for the skilled nursing services. Our reviewer
says that based on the limited documentation provided, the denial of the skilled home health services is
appropriate. Our physician reviewer found that you do not have documented skilled nursing needs. As such, the
requested home health nursing services are not shown to be medically necessary or reasonable.

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 skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for direct skilled nursing services of a registered nurse (RN) in a home health setting
(G0299).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the tooth extraction (D7140) provided on March 29, 2021.

You asked the Plan to pay for the tooth extraction. You say that the extraction was medically necessary. The Plan denied your request. The Plan says your dental benefits do not cover tooth extractions.

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 tooth extraction (D7140) provided on March 29, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy (90837) rendered by the out of network (OON) provider on June 16, 2020.

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 psychotherapy (90837) rendered by the out of network (OON) provider on June 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out of network (OON) provider on February 2, 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 laboratory services rendered by the out of network (OON) provider on February 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on April 1, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.

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 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 services provided to you by an out-of-network provider on April 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fluoracil cream 5% for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says there is no Part D benefit.

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 pre-approve Fluoracil cream 5% for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment, abutment supported porcelain, first intraoral periapical x-ray, and recement of a fixed partial denture provided on August 6, 2020.

You asked the Plan to pay for the custom fabricated abutment, abutment supported porcelain, first intraoral periapical x-ray, and recement of a fixed partial denture. You say that you believe the enrollee's dental problems are a direct result of the stroke, and should be covered under their medical plan. The Plan denied your request. The Plan says the enrollee has met their annual maximum benefit. The Plan also says that the caries and pulpitis are not direct results from the enrollee's stroke.

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 Plan offers a $2,000 allowance for covered dental services. The contract says that the enrollee has to pay 100% of charges beyond the $2,000 allowance. The record shows that the enrollee met the annual maximum benefit while processing this claim for the August 8, 2020 date of service and the enrollee's annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment, abutment supported porcelain, first intraoral periapical x-ray, and recement of a fixed partial denture provided on August 6, 2020.
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 you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter you do not require the necessary services on 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 4, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved.

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 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 services provided by an out-of-network provider on October 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health treatment.

You asked the Plan to pre-approve inpatient mental health treatment. 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 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 mental health treatment. Our
reviewer says that the services are not medically necessary.

Our physician reviewer found based upon review of the records provided, this enrollee does not meet the
criteria for treatment in an acute inpatient mental health treatment beyond the date in question of July 9, 2021
forward and could have been treated in a lesser restrictive setting. The enrollee was not showing any suicidal or
homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or
aggression. The enrollee was being cooperative and compliant while not showing any acute threats to safety.

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 mental health treatment have not been met. Therefore, we decided that
the Plan does not have to pre-approve inpatient mental health treatment.