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

We decided that the Plan does not have to pre-approve a lifetime use of a Freestyle Libre continuous glucose
monitor (CGM).
You asked the Plan to pre-approve a lifetime use of a Freestyle Libre CGM. You say that the enrollee needs
this because he cannot use lancets. The Plan denied your request. The Plan says a lifetime use is not covered.
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 the enrollee does not use insulin
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a lifetime use
of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve
a lifetime use of a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis, aspiration and/or injection, major joint or bursa (20610) provided from August 21, 2020, through October 16, 2020.
You asked the Plan to waive the copayment for aspiration and/or injection of large joint or joint capsule. You say that you have never had to pay a facility charge when seeing this provider in the past. The Plan denied your request. The Plan says if you see a provider that is part of a hospital-based or provider based practice, you will pay your outpatient hospital clinic or facility cost-share plus the primary care or specialty care provider office visit cost-share.
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 $100 copayment for outpatient hospital facility. You have been asked to pay a $100 copayment for aspiration and/or injection of large joint or joint capsule. The services at issue fall within the outpatient hospital observation 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 arthrocentesis, aspiration and/or injection, major joint or bursa (20610) provided from August 21, 2020, through October 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services.

You asked the Plan to pay for the dermatology services. You say that you need to be seen by another specialist in order to figure out what is going on with your rash. The Plan denied your request. The Plan says the provider is out-of-network, however, the Plan has authorized services with an in-network provider.

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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the dermatology services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four semi-precision attachments to abutments (D6052 x4).
You asked the Plan to pre-approve the semi-precision attachments. The Plan denied your request. The Plan says this service is not a covered benefit.
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 pre-approve four semi-precision attachments to abutments (D6052 x4).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve exercise equipment (A9300).

You asked the Plan to pre-approve exercise equipment. You say that you need the exercise equipment to continue your conditioning at home. The Plan denied your request. The Plan says exercise equipment is not covered by Medicare or the Plan.

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 exercise equipment (A9300).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medial branch nerve blocks (MBBs) for the enrollee.
You asked the Plan to pre-approve the blocks. You say that the enrollee has tried unsuccessful extensive
conservative management to alleviate the symptoms. The Plan denied your request. The Plan says this is
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 blocks. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the records show that the patient has pain traveling down the arm. This is a contraindication to medial
branch block cervical facet injections.
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 blocks have not been met. Therefore, we decided that the Plan does not have
to pre-approve medial branch nerve blocks (MBBs) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a duplex scan of extracranial arteries.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of symptoms related to impaired blood flow.
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 scan. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support the medical necessity of the study in question. You do not complain of neurologic symptoms attributable to carotid disease, and there is no documentation of a carotid bruit. You do not have significant peripheral artery disease of the severity requiring treatment. The request is essentially for a screening duplex which is not covered under your plan. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a duplex scan of extracranial arteries.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device and appliances to be provided by an out of network provider.

You asked the Plan to pre-approve a pneumatic compression device (E0652) and appliances (E0667) from an out of network provider. You say that you are the only supplier of this brand specific device. The Plan denied your request. The Plan says they have providers who can supply a pneumatic compression device and appliances.

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 at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device and appliances to be provided by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy.

You asked the Plan to pre-approve the massage therapy. You say that you would like reconsideration because massage therapy will help you to regain your active, healthy lifestyle. The Plan denied your request. The Plan says Medicare does not consider services provided by a massage therapist reasonable and necessary.

The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed to show safety and efficacy of the device. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve the additional trips. You say that you need this for dialysis trips. The Plan denied your request. The Plan says the benefit has been exhausted.

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 one-way 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 pre-approve additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Floweraminoflo injection.

You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says there is not
enough medical evidence that shows it is helpful for the treatment or prevention of ligament and tendon
injuries.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
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 injections. Our physician
reviewer found that you have a history of osteoarthritis of the shoulder. There is no documentation that
Floweraminoflo is FDA-approved for your diagnosis. The requested use is not supported by one of the major
drug compendia or by clinical research that appears in a CMS-approved medical journal. It is not listed as not
indicated, not supported or not recommended in any of the compendia. The documentation does not support
that the requested drug is safe and effective, and otherwise reasonable and 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 injections have not been met. Therefore, we decided that the Plan
does not have to pre-approve a Floweraminoflo injection.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram.
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that you think there
should be no cost share for this procedure. The Plan denied your request. The Plan says the service performed
was diagnostic, not routine, therefore the correct copayment applied.
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
copayment for outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a $20 copayment for the diagnostic mammogram. the diagnostic mammogram
falls 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 the diagnostic mammogram.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy services.

You asked the Plan to waive the copayment for the physical therapy services. You say that the plan issued a copayment waiver for specialist visits. The Plan denied your request. The Plan says physical therapy services are not considered medical specialist services.

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 $40 copayment for outpatient rehabilitation services. In addition, physical therapy is not considered medical specialist services, therefore these claims are not eligible for the copayment waiver. 

You have been asked to pay a total of $160 in copayments (a $40 copayment for each of 4 dates of service) for the physical therapy services. The physical therapy services fall within the outpatient rehabilitation 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 physical therapy services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound-guided breast biopsy (19083-52).

You asked the Plan to waive the copayment for an ultrasound-guided breast biopsy. You say that the biopsy was never done because they were unable to find nodes to biopsy. The Plan denied your request. The Plan says the copayment was applied 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 $200 copayment for outpatient surgery.

You have been asked to pay a $200 copayment for an ultrasound-guided breast biopsy. An ultrasound-guided breast biopsy falls within the outpatient surgery benefit category. Although the service was not completely performed, it was billed appropriately to indicate reduced services because they failed to find anything to biopsy. 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 ultrasound-guided breast biopsy (19083-52).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic facet injections.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the
enrollee has not tried conservative measures, and it is not clear that other issues have been ruled out as the
source of pain.
The Plan follows Medicare rules. Medicare rules say that facet injections are only covered under certain
medical indications.
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 the enrollee has chronic neck pain. She has taken oral analgesics, and received trigger point
injections. Coverage criteria requires conservative care, such as physical therapy, prior to injections. This has
not occurred, therefore, the request is deemed 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 requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve therapeutic facet injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve seat lift mechanism (E0627)
You asked the Plan to pre-approve seat lift mechanism. You say that this service is medically necessary. The Plan denied your request. The Plan says criteria for coverage are not met.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met. 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 seat lift mechanism. Our reviewer says that the service is not medically necessary. Our physician reviewer found although the medical records provided indicate that there is documentation of severe arthritis of the hip and a neuromuscular disease and that the seat lift is likely to effect improvement in the patient's condition, the medical records do not show that the patient is completely incapable of standing from a chair in the home. Because the medical records do not show that the patient is completely incapable of standing from a chair in the home, the criteria for a seat lift mechanism are not fully 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 seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve seat lift mechanism (E0627)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cologuard testing.
You asked the Plan to pre-approve Cologuard testing. The Plan denied your request. The Plan says the coverage criteria are not met.
The Plan follows Medicare rules. Medicare rules say that Cologuard testing is covered once every three years. 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 Cologuard testing. Our reviewer says that the requested Cologuard testing is not medically reasonable and necessary. Our physician reviewer found that the time frame for coverage of a repeat Cologuard testing is not met. Coverage under Medicare rules for subsequent Cologuard testing for the enrollee may next be provided on March 27, 2022. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Cologuard testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Cologuard testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an impression and custom preparation; mandibular resection prosthesis, maxillary impression for palatal prosthesis, and supplies and materials.
You asked the Plan to pre-approve the TMJ splint. You say that this is not a dental prosthesis, but something medical that you need. The Plan denied your request. The Plan says these services are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. The Plan also says that jaw or dental treatment related to TMJ is not covered by Medicare under any condition. Therefore, we decided that the Plan does not have to pre-approve an impression and custom preparation; mandibular resection prosthesis, maxillary impression for palatal prosthesis, and supplies and materials.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator, any type, used with non-invasive interface (e0466) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the noninvasive ventilator. You say that the doctor recommended this machine for you when you were in the hospital. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 the home ventilator, any type, used with non-invasive interface (e0466) to be provided by an out of network (OON) provider.