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

We decided that the Plan does not have to pre-approvecontinued Entyvio infusions, 300 mg, every 6 weeks.You asked the Plan to pre-approvethe continuation of Entyvio infusions every 6 weeks. You say that you have been administering Entyvio infusions every 6 weeks. You say that the enrollee needs to continue the regimen. You say that the enrollee is in active Crohn's and has been placed back on prednisone.The Plan denied your request. The Plan says the request for 300 mg every 6 weeks for 1 year exceeds the dose allowed per the clinical policy of 300 mg every 8 weeks. The Plan also says that the criteria has not been met.The Plan mustfollow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 continuation of Entyvio infusions. Our reviewer says that the continued maintenance dosing of Entyvio every 6 weeks is not medically necessary. Our physician reviewer foundthe provided documentation does not provide no objective data to support failure by the enrollee to respond to dosing every 8 weeks instead of every 6 weeks. Therefore, the reviewer found that the continued maintenance dosing of Entyvio every 6 weeks is 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 continuation of Entyvio infusions have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued Entyvio infusions, 300 mg, every 6 weeks
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvebilateral custom orthotics.You asked the Plan topre-approvefoot orthotics. You say that this is medically necessary.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvebilateral custom orthotics
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the L300 Go Advanced FES system.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has not satisfied all Medicare criteria for this device.
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 according to the applicable NCD, FES devices are only covered for use in patients with a history of SCI, when additional criteria for coverage are met. These requirements include that a patient have an at least 6-month post recovery spinal cord injury and restorative surgery. In this case, you have a history of transverse myelitis but not a spinal cord injury. You do not a history of having undergone surgery. Inasmuch, the criteria for coverage of the requested device is not 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the L300 Go Advanced FES system.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services and an electrocardiogram provided
on October 2, 2020.
You asked the Plan to pay for the emergency room services and the electrocardiogram. You say that the claim
was billed with an appropriate diagnosis and that the enrollee was in need of care as illustrated by your medical
records. The Plan denied your request. The Plan says the claim was submitted with an inappropriate primary
diagnosis code based on the ICD-10-CM Manual as it is a secondary only diagnosis which cannot be used as
the primary, first-listed or principal diagnosis for any procedure or service.
The Plan must follow Medicare rules. Medicare rules say that health plans, physicians, hospitals, and other
health care providers must comply with the Official ICD-10-CM Coding Guidelines.
We looked at the file and Medicare rules. The records show that the first diagnosis code on the claim was
I70.92. Prior to reporting the total occlusion, the underlying condition of atherosclerosis needs to be reported.
That was not the case for this claim. Based on this information, we decided that Medicare rules for coverage of
the emergency room services and the electrocardiogram have not been met. Therefore, we decided that the Plan
does not have to pay for emergency room services and an electrocardiogram provided on October 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay formultiple self-administered drugs received on July 22 to July 23, 2020.You askedthe Plan to pay forself-administered drugs. You say that you do not believe this amount should have been disallowed.The Plan denied your request. The Plan says rules for payment have not been met.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay formultiple self-administered drugs received on July 22 to July 23, 2020.Benefits for self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the orthopedic consult to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the out-of-network consult. You say that you prefer the out-of-network provider. The Plan denied your request. The Plan says there are network providers available that can provide the service at issue.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that if the enrollee uses out-of-network providers in cases other than emergency or urgent care, they are responsible for any amounts not covered by Original Medicare. 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 cover these services at the in-network rate. Therefore, we decided that the Plan does not have to pre-approve the orthopedic consult to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe orbitocranial approach to anterior cranial fossa (61584) and resection or excision of neoplastic (61600) to be provided by an out of network (OON) provider.You asked the Plan to pre-approveorbitocranial approach to anterior cranial fossa and resection or excision of neoplastic. You say that the service is medically necessary.The Plan denied your request. The Plan says these services can be obtained 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 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-approvethe orbitocranial approach to anterior cranial fossa (61584) and resection or excision of neoplastic (61600) to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided.

You asked the Plan to pay for the self-administered drugs. You say that these drugs were provided by your doctors, and are required for your health. The Plan denied your request. The Plan says self-administered drugs are not a covered 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 pay for the self-administered drugs provided. 

Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthrocentesis (20610) and  non-prescription drugs (A9150) provided on May 22, 2020, through June 25, 2020.

You asked the Plan to pay for the arthrocentesis and non-prescription drugs. You say that you would like reconsideration because you sought this surgery so that you would not have to move out of your home for two months. The Plan denied your request. The Plan says this type of provider is not part of the Medicare Program.

The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. 

The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have to pay for the arthrocentesis (20610) and  non-prescription drugs (A9150) provided on May 22, 2020, through June 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve morphine sulfate tablets.
You asked the Plan to pre-approve morphine sulfate tablets. You say that the enrollee has had results on this medication and should not change medications. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.
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 morphine sulfate tablets.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81401) provided on May 28, 2020.
You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed with a correct POS.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. These services were billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the independent laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81401) provided on May 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
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 service 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 these services. Our reviewer says that the service are not medically necessary. Our physician reviewer found the enrollee has a history of back pain. The requested Superion spacer is considered experimental in nature, as more research is needed to show safety and efficacy. The services are therefore 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 a Vertiflex Superion spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the progressive lens provided on October 26, 2020 by an out of network (OON) provider.
You asked the Plan to pay for progressive lens. You say that the service should be covered. The Plan denied your request. The Plan says services must be obtained in-network to be covered.
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 progressive lens provided on October 26, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTacrolimus.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plandenied your request. The Plan says self-administered drugs are not covered.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-approveTacrolimus.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for contact lens (V2531) purchased on September 25, 2020.
You asked the Plan to pay for contact lens. You say that the requested item is medically necessary. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules say that Medicare does not cover low vision aids. The item you asked the Plan to pay for is considered a low vision aid. The exceptions listed above to Medicare's rule for low vision aids do not apply in this case. The Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. The case record indicates the requested item is not routine. Therefore, we decided that the Plan does not have to pay for contact lens (V2531) purchased on September 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on June 29, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says records were not received.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 9, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 did not pre-approve the physician's services. 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 physician's services provided on January 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Provigil Tab 200 mg.
You asked the Plan to pre-approve Provigil. You say that the item is medically necessary. The Plan denied your request. The Plan says this item is not covered under the Plan's benefits.
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 Provigil Tab 200 mg.
Benefits for Provigil may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. 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.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 the enrollee was admitted to the hospital with a dislodged chest tube. The enrollee was diagnosed with pneumonia, septic shock, respiratory failure, and suffered a cardiac arrest. The enrollee is now on minimal oxygen via nasal cannula. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no required medical services identified that are available at the LTACH, that arenot available at the current health care setting being offered by the health 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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for eye refraction services provided on August 12, 2020.
You asked the Plan to pay for the eye refraction services. You say that you went to the participating provider because you noticed blips in a straight horizontal line. You say that it was difficult to read the daily paper. You say that the doctor checked everything and when he was done, he check to see if your glasses were correct. You say that they were not, and the doctor wrote a prescription for a new pair, and told you to come back in 6 months. You questioned whether you were supposed to tell the participating provider not to do a refraction while you were there. The Plan denied your request. The Plan says that the refraction services are not covered because the visit was not routine.
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. You were referred for the eye refraction services by a contract provider. The service in dispute could be covered under some conditions, and therefore the EOC alone is not adequate notice of non-coverage. The file does not show that the Plan provided notice that the eye refraction services would not be covered. Under Medicare rules, this means the eye refraction services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for eye refraction services provided on August 12, 2020.
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.