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

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee has not met the step therapy requirements.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Prolia. Our reviewer says that Prolia is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial of drug zoledronic acid before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug. There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (CPT 90832) provided to the enrollee on September 25, 2020.
You asked the Plan to pay for the services. You say that per Medicare guidelines, this was filed with a valid POS. The Plan denied your request. The Plan says POS 31 is invalid for CPT 90832.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 90832 is "individual psychotherapy services rendered for 30 minutes by a licensed mental health provider." We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the documentation supports that the services was provided while the enrollee was in a skilled nursing facility, and reported with a place of service 31. Per Medicare guidelines "Covered POS include: office (11), inpatient (21) and outpatient (22) for the following codes: CPT 90832 (or + 90833): 16 to 37 minutes, CPT 90834 (or +
90836): 38 to 52 minutes, or CPT 90837 (or + 90838): 53 minutes or longer". We looked at this coder's review, the file, and Medicare rules. 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 psychotherapy services (CPT 90832) provided to the enrollee on September 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Contour Next in-vitro test strips.
You asked the Plan to pre-approve the test strips. You say that this is medically necessary. The Plan denied your request. The Plan says the non-formulary exception rules are not met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the test strips. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided records do not demonstrate the medical necessity or reasonableness, as defined by Medicare rules, of the requested service.
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 test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve the Contour Next in-vitro test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmological services provided on January 26, 2021 by an out of network provider.
You asked the Plan to pay for the ophthalmological services. You say that a provider performing services in a nursing home facility is not responsible to obtain authorization. The Plan denied your request. The Plan says the provider did not request prior authorization for the non-emergent 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 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 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 ophthalmological services provided on January 26, 2021 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the lab services provided on August 7, 2020.
You asked the Plan to waive the copay for the labs. You say that you were advised the lab would be fully
covered. The Plan denied your request. The Plan says the claim processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10
copay for lab services.
You have been asked to pay a $10 copay for lab services. The labs fall within the outpatient diagnostic tests
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 copay for the lab services provided on August
7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on July 27, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that these services were medically necessary. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider or the member's primary care physician.
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 physician services provided on July 27, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis provided from January 1, 2021,
through January 30, 2021.
You asked the Plan to waive the coinsurance for dialysis. You say that the bill is excessive, and you were told
the bill should be reprocessed by insurance. The Plan denied your request. The Plan says the coinsurance
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 20%
coinsurance for Medicare-covered benefits for outpatient dialysis treatments.
You have been asked to pay $50, which is 20% of the allowed amount for each dialysis treatment. The total
amount you owe is $1,100 ($50/treatment x 22 treatments = $1,100). Dialysis falls within the "Services to Treat
Kidney Disease" benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for dialysis provided
from January 1, 2021, through January 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311) and gel foot plate covers (K0108).
You asked the Plan to pre-approve an expandable controller and gel foot plate covers. You say that these items are medically necessary. The Plan denied your request. The Plan says the power options can be controlled through their own switches and the gel foot plate covers are not 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 an expandable controller and gel foot plate covers. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's function in the upper extremities and ability to perform multiple activities of daily living indicate that the patient can control any power options through their own individual switches, meaning an expandable controller is not necessary. The documentation also does not show any extenuating factors that require gel foot plates. There is no given reason that the patient is unable to wear protective footwear with the foot plates if needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller and gel foot plate covers have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311) and gel foot plate covers (K0108).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laser hair removal.
You asked the Plan to pre-approve laser hair removal. You say that laser hair removal is part of the enrollee's medically necessary treatment. The Plan denied your request. The Plan says this treatment is considered cosmetic and not covered.
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 laser hair removal. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records provided are insufficient to determine the medical necessity and reasonableness, as defined by Medicare rules. The elements of the coverage criteria are not satisfied. The requested service is not recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of laser hair removal have not been met. Therefore, we decided that the Plan does not have to pre-approve laser hair removal.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight testing provided on November 9, 2020.
You asked the Plan to pay for the testing services. You say that the test provides a more accurate prediction of the enrollee's response to medications. The Plan denied your request. The Plan says the testing is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. There is insufficient evidence to support widespread use of combinatorial pharmacogenetic decision support tools. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight testing provided on November 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on
December 21, 2020.
You asked the Plan to pay for the testing services. You say that The Plan denied your request. The Plan says
Medicare denies coverage for all cardiovascular risk assessment testing, except the basic lipid panel.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
We looked at the file and the rules. The records provided do not clearly document the intent for the services to
be provided. The records do not show that the testing was ordered to treat a specific medical problem. The test
at issue in this appeal was requested for screening purposes. Medicare does not cover this tetsing for screening
purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular screening
provided on December 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient post-stabilization service provided on September 25, 2020, through September 27, 2020.
You asked the Plan to pay for inpatient post-stabilization service provided on September 25, 2020, through September 27, 2020. You say that the service was medically necessary. The Plan denied your request. The Plan says the enrollee's emergency medical condition stabilized on September 24, 2020, and subsequent care was post stabilization care, not approved in compliance with the health plan's authorization procedures.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient post-stabilization service. Our reviewer says that the post-stabilization care services provided on September 25, 2020, through September 27, 2020, at the out-of-network facility, were not medically necessary or reasonable. Our physician reviewer found the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. The review also indicates that as of September 24, 2020, the enrollee was stable for ambulance transport with monitoring to a Plan facility. 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 post-stabilization service have not been met. Specifically, the enrollee was stable for transfer and could have received care from an in-network facility. Prior authorization was not obtained to receive the post stabilization care at an out-of-network facility. Therefore, we decided that the Plan does not have to pay for inpatient post-stabilization service provided on September 25, 2020, through September 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laboratory services provided to the enrollee on December 15, 2020.
You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your request. The Plan says the services are not considered urgent or emergent in nature.
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 rendering 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 laboratory services provided to the enrollee on December 15, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Kynmobi Mis 10mg.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is denied as a benefit exclusion.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Kynmobi Mis 10mg.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating provider on February 5, 2021.
You asked the Plan to waive the copayment for an ultrasound. You say that you went for you annual wellness exam. You say that this should be covered. The Plan denied your request. The Plan says the correct copayment has been 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 $110 copayment for outpatient diagnostic tests/diagnostic radiology services.
You have been asked to pay $94.19 which is less than your copayment amount of $110 for an ultrasound. The correct copayment has been applied to the services that were provided. An ultrasound falls within the outpatient diagnostic tests/diagnostic radiology 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 an ultrasound provided by a participating provider on February 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zolpidem.
You asked the Plan to pre-approve Zolpidem. You say that Zolpidem is essential to your wellbeing. The Plan denied your request. The Plan says this medication does not fall under Part B.
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 Zolpidem.
Benefits for Zolpidem 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 waive the copayment for an office visit with a specialist (99214) provided on February 12, 2021.
You asked the Plan to waive the copayment for an office visit. You say that you have seen this provider in the past and you did not pay a copayment. The Plan denied your request. The Plan says the copayment you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for physician/practitioner services, including doctor's office visits with a specialist.
You have been asked to pay a $10 copayment for an office visit with a specialist. Your Plan's 2020 EOC confirms you had a $0 copayment for a specialist visit. Your Plan's 2021 EOC confirms that $10 is the required copayment for this service. An office visit with a specialist falls within the physician/practitioner services, including doctor's office visits 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 an office visit with a specialist (99214) provided on February 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided December 2, 2020.
You asked the Plan to pay for the ambulance service. You say that your mother had a stroke at the optometrist office and 911 was called to take her to the hospital. You received a bill for $581. You are low income and cannot afford this bill. Your mom is 86 years old. The Plan denied your request. The Plan says this service is not covered under Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on December 2, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided December 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an adjustable bed for the enrollee.
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says there is no prescription from the provider for this bed.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 bed. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the documentation does not reveal that the enrollee's condition has failed normal positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for an immediate or frequent change in body position or special attachments that cannot be fixed on an ordinary bed. There is no objective physician prescription for this bed included in the documentation. 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 bed have not been met. Therefore, we decided that the Plan does not have to pre-approve an adjustable bed for the enrollee.