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

We decided that the Plan does not have to pre-approve a Trilogy portable ventilator.

You asked the Plan to pre-approve the Trilogy ventilator. You say that this particular ventilator is necessary for the patient. The Plan denied your request. The Plan says the enrollee does not require the type of ventilation offered by this device. The enrollee's needs can be met with bi-level positive airway pressure (BiPAP) support.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Trilogy ventilator. Our reviewer says that the criteria for coverage of the requested ventilator are not met in this case. Our physician reviewer found the record indicates that the enrollee has chronic respiratory failure due to chronic obstructive pulmonary disease. The record indicates an exacerbation of hypercarbia with a partial pressure of carbon dioxide (pCO2) of 70 compared to 45 the previous day during a a hospital admission but no follow up is provided. The record indicates that the ventilator mode is Average volume-assured pressure support (AVAPS). The plan indicates that this can be achieved with an available BiPAP machine.

The record does not provide enough detailed information to justify the treatment selected. The elements of the coverage rule are not satisfied.

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 Trilogy ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a Trilogy portable ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation (99203) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a consultation. You say that the service is medically necessary. The Plan denied your request. The Plan says there are in-network provider who can provide this service.
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 a consultation (99203) to be provided by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.

You asked the Plan to pre-approve ventilator. You say that without this equipment, the enrollee is prone to readmission to a hospital or harm to health. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because this device is not covered for use in the bi-level positive airway pressure (BiPAP) mode rather than being used as a home ventilator.

The Plan must follow Medicare rules. Medicare rules say that a ventilator is not covered when used to provide CPAP or BiPAP therapy. 

We looked at the file and Medicare rules. This ventilator is not covered by Medicare for the requested use. Based on this information, we decided that Medicare rules for coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal fusion surgery with an inpatient stay.
You asked the Plan to pre-approve spinal fusion surgery represented by the codes 63047, 22840, 63048, 22633, 22853, and 20936. You say that the enrollee would like to pursue surgery. The Plan denied your request. The Plan says the enrollee does not meet any of the requirements.
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 spinal fusion surgery represented by the codes 63047, 22840, 63048, 22633, 22853, and 20936. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is also limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for inpatient L4-L5 left-sided minimally invasive surgery with transforaminal lumbar interbody fusion and posterior-lateral spinal fusion 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 spinal fusion surgery represented by the codes 63047, 22840, 63048, 22633, 22853, and 20936 have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal fusion surgery with an inpatient stay.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on March 17, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory work. You say that you were unaware a prior authorization was needed, and this service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. The record shows the referring provider was also out-of-network. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on March 17, 2021 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve the home health services.. You say that you would like reconsideration 
because the home health services are medically necessary. The Plan denied your request. The Plan says the 
records do not show that the member is confined to the home or has a need for home health services. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home health services.. Our reviewer 
says that the records do not show that skilled nursing and/or therapy services are required to effectively provide 
treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the member's condition and/or prevent deterioration. Our physician reviewer 
found the member does not meet CMS criteria for coverage. 
 
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 home health services. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a continuous glucose monitor
You asked the Plan to preapprove the continuous glucose monitor. You say that the device is required. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria.
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 and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 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 requiring 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 the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to preapprove a continuous glucose monitor
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the transthoracic echocardiography (TTE) you had on February 4, 2021, and the cardiac catheterization procedure you had on February 24, 2021 at an outpatient hospital facility.
You asked the Plan to waive the cost sharing for the TTE and cardiac catheterization. You say that you believe you are being billed for testing for the coronavirus. You also say that you think the cost of the services you received is too high. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that this cost sharing is not for testing for the coronavirus.
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 $45 copayment for diagnostic procedures and tests, a $1000 deductible that applies to outpatient hospital services, and a $375 copayment for outpatient surgery. Records show that you had a TTE and a cardiac catheterization procedure. You have been asked to pay a $45 copayment for the TTE. In addition, you had not yet met your $1000 deductible at the time of you cardiac catheterization. After the $1000 deductible, you were assessed a copayment of $375 because the cardiac catheterization is considered an outpatient surgery procedure. This means that you have been asked to pay the correct amounts 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 cost sharing for the transthoracic echocardiography (TTE) you had on February 4, 2021, and the cardiac catheterization procedure you had on February 24, 2021 at an outpatient hospital facility.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require any skilled nursing or skilled therapy 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 the SNF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the abdominal ultrasound provided on April 7, 2021.

You asked the Plan to waive the copayment for the abdominal ultrasound. You say that the enrollee is on a limited income and cannot afford this copayment. The Plan denied your request. The Plan says this copayment was charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $100 copayment for ultrasounds. 

The enrollee has been asked to pay a $100 copayment for the abdominal ultrasound. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the abdominal ultrasound provided on April 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
You asked the Plan to provide a therapeutic continuous glucose monitor (K0554, K0553). You say that the enrollee needs a CGM. The Plan denied your request. The Plan says the enrollee does not inject insulin three or more times a day.
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 and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor (K0554, K0553) have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home blood pressure monitor. 
 
You asked the Plan to pre-approve blood pressure monitor. You say that you are not receiving home dialysis 
and have never received home dialysis. The Plan denied your request. The Plan says the denial of authorization 
for this item is correct, because this blood pressure monitor is not covered by Medicare except for patients on 
home dialysis. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules state that blood pressure monitoring devices are included in the end-stage renal 
disease benefit.

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. You do not have 
end-stage renal disease and are not on home dialysis, therefore, this item would not be covered under the end-
stage renal disease benefit. Therefore, we decided that the Plan does not have to pre-approve a home blood 
pressure monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on December 7, 2020, by an
out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that the member went into your office in terrible pain and
there was no time to discuss insurance information or request authorization as it was an emergency. The Plan
denied your request. The Plan says services were provided 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 requested provider in this case is not a network provider with the Plan. The records provided for review do
not show that the services at issue were urgent or emergent. 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 an office visit (99214) provided on December 7, 2020, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient office visit (99205, 99215) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve office visit. You say that the requested facility is the closest provider to you. The Plan denied your request. The Plan says there are providers in network you can receive this service from.
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 outpatient office visit (99205, 99215) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (K0813).
You asked the Plan to pre-approve a power wheelchair. You say that walking in the store causes your blood pressure to rise and you have a variety of other health issues. The Plan denied your request. The Plan says the requirements for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that a power mobility device (PMD) will not be covered if the patient does not have mobility deficit that impairs their participation in mobility related activities of daily living (MRADLs), the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The rules also say that prior to or at the time of
delivery of a power wheelchair, the supplier or practitioner must perform an on-site evaluation of the beneficiary's home to verify that the beneficiary can adequately maneuver the device that is provided considering physical layout, doorway width, doorway thresholds, and surfaces. The file does not show that you have a mobility deficit that impairs your participation in MRADLs. The file also does not show that a home evaluation has been performed. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (K0813).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexamethason tablets.
You asked the Plan to pre-approve Dexamethason tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Dexamethason tablets not being used as anti-emetic to be administered with chemotherapy is not covered under the enrollee's Medicare Part B benefit. The requested drug is to be self-administered by the enrollee.
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 Dexamethason tablets.
Benefits for Dexamethason tablets 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Allograft (20931), Arthrodesis (22551, 22552), Anterior 
Segmentation (22845), Arthrodesis Anterior Interbody W/Mininmal Diskectomy; Cervical Below C2 (22554) 
and Insertion of interbody biomechanical device (22853) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the objective findings on imaging do not match the documentation 
provided. 
 
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 requested services are not considered medically reasonable and necessary in this case. The imaging studies 
do not support the diagnosis of fusio0n failure and severe stenosis. There is no instability. Our physician reviewer found that the enrollee's condition does not meet criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Allograft (20931), Arthrodesis (22551, 22552), Anterior Segmentation (22845), 
Arthrodesis Anterior Interbody W/Mininmal Diskectomy; Cervical Below C2 (22554) and Insertion of 
interbody biomechanical device (22853) for the enrollee.