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

We decided that the Plan does not have to pre-approve a continuous glucose monitor and supplies.You asked the Plan to pre-approve the monitor and supplies. You say that this is medically necessary.The Plan denied your request. The Plan says the clinical records do not indicate that the enrollee is on insulin injections 3 or more times per day, and requires frequent adjustments. 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 monitor and supplies. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are noted to be a type II diabetic, who takes a set dose of mixed insulin twice daily to treat his diabetes. How often you were previously checking your blood glucose is unknown, but you were recently ordered to increase the frequency of testing to four times day. There is no evidence that you were using the results of whatever testing you were previously doing to self-adjust the dose of your self-administered insulin multiple times a day.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 monitor and supplies have not been met.Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the total electric hospital bed with mattress (E0265). You asked the Plan to pre-approve the total electric hospital bed with mattress. You say that you have a semi-electric bed that doesn't work for the therapies you receive at home. You need to move from the bed to the chair and you require the bed to go up and down.The Plan denied your request. The Plan says this service is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approve the total electric hospital bed with mattress (E0265).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha (C9399).You asked the Plan to pre-approve Repatha. You say that this is medically necessary.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 Repatha (C9399). Benefits for Repatha 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: Imaging
Decision: Unfavorable

We decided that thePlan does not have to pre-approve the requested screening mammogram.You asked the Plan to pre-approve the screening mammogram.You say that you would like to continue to get a mammogramdone with this provider as they have followed you for years.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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested screening mammogram.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on January 10, 2020.You asked the Plan to waive the copayment forthe specialist office visit. You say that you should have no copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.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 $50 copayment for specialist visits. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $50 copayment for the specialist office visit.You have been asked to pay a $44.23 copayment for the specialist office visit. The specialist office visit 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 forthe specialist office visit provided on January 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelow vision aids (V2615).You asked the Plan to pre-approvethe low vision aids. You say that you would like reconsideration because the member requires special glasses for reading to improve independence.The Plan denied your request. The Plan says the member has no light perception, therefore reading glasses will not help her to see.The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pre-approve are considered routine vision services or eyewear.Therefore, we decided that the Plan does not have to pre-approvelow vision aids (V2615).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy guidelines were not followed.
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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has not tried and failed the requested drug - Retracrit. Based on the medical records provided there is no indication that the plan's required drug 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services (99204, 98942, 98941, 99214).
You asked the Plan to pre-approve chiropractic services. You say that this should be covered. The Plan denied your request. The Plan says the records do not show you have a subluxation.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. We looked at the file and Medicare rules. There is no documentation of a physical exam or x-ray demonstrating that you have a subluxation. Based on this information, we decided that Medicare rules for coverage of chiropractic services have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic services (99204, 98942, 98941, 99214).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injections provided from February 18, 2020 to March 31, 2020.
You asked the Plan to waive the coinsurance for the Part B injections. You say that you cannot afford food because of the cost of of the bills and cannot keep up with payments. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 Part B drugs that are administered by a provider. You have been asked to pay a total of $600.76 coinsurance for the Part B injections. The Part B injections fall within the "Medicare Part B prescription drugs" benefit category. See chart below.

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 the Part B injections provided from February 18, 2020 to March 31, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation trips.
You asked the Plan to pre-approve the routine transportation trips. You say that, due to the enrollee's medical conditions, he has frequent appointments that make it difficult for him to ambulate. You say that, in order to reduce the risk of infectious disease exposure, it is highly recommended that the enrollee get the transportation services being requested. The Plan denied your request. The Plan says routine transportation is not covered by the enrollee's benefit plan.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of the routine transportation trips have not been met. Therefore, we decided that the Plan does not have to pre-approve routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea tooth extraction.You asked the Plan to pre-approvea tooth extraction. You say that the service is necessary.The Plan denied your request. The Plan says the requested 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, wedecided that the Plan does not have to pre-approvea tooth extraction.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea blood pressure device.You asked the Planto pre-approvethis is medically necessary.. You say that it is not fair that a heart condition is not covered.The Plandenied your request. The Plansaysthe doctor's notes do not show ESRD, or dialysis.The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.Therefore, we decided that the Plandoes not haveto pre-approvea blood pressure device
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair (K0001). You asked the Plan to pre-approve a manual wheelchair. You say that this should be covered.The Plan denied your request. The Plan says the record shows that you reside in a skilled nursing facility.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that a manual wheelchair is being requested for use in a SNF or hospital.Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair (K0001).
Appeal type: Outpatient Therapies
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 have tried a hip injection and this
was painful and did not help your condition. When you went to massage therapy and told them where your pain
was they were able to relieve it easily. You feel that this should be covered. The Plan denied your request. The
Plan says this treatment is experimental.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing coded 81120, 81121, 81173, 81201,
81210, 81235, 81270, 81272, 81275, 81276, 81293, 81301, 81310, 81311, 81314, 81321, 81400, 81401, 81402,
81403, 81404, 81405, and 81406 provided on January 31, 2020.
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes 81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81276, 81293,
81301, 81310, 81311, 81314, 81321, 81400, 81401, 81402, 81403, 81404, 81405, and 81406 are not supported
in the medical record. Specifically, code 81479 is required to report the Gurdant360 molecular testing. In
addition, the appropriate DEX Z Code identifier must be entered adjacent to CPT code 81479 in the
comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the
Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the
Guardant360 testing coded 81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81276, 81293,
81301, 81310, 81311, 81314, 81321, 81400, 81401, 81402, 81403, 81404, 81405, and 81406 provided on
January 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor
You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee states she tests typically 8-10 times per day and injecting insulin 4-8 times a day and you are appealing the denial. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for the requested continuous glucose monitor.
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 a continuous glucose monitor. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found The enrollee is a type II diabetic, who reportedly uses both a short-acting and long-acting insulin to treat her diabetes. The enrollee apparently started using a CGM and since that time she reportedly has been checking her blood glucose frequently and injecting herself with insulin frequently. Unfortunately, it is not known what the enrollee is actually ordered to do with her testing and medication, or what she was doing prior to starting with the CGM. Specifically, it is not demonstrated that the enrollee was testing her blood glucose multiple times a day and using these results to self-adjust her insulin multiple times per day. The documentation does not show necessity or compliance prior to obtaining the CGM. Therefore, the CGM is not shown to be medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown lengthening provided on February 12, 2020.
You asked the Plan to pay for the crown lengthening. You say that the dentist billed this separately, but this was part of the total procedure. The Plan denied your request. The Plan says the 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 pay for the crown lengthening provided on February 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for two units of CPT 70450 provided on January 21, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says only one unit of this service is supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We find that 2 units of CPT code 70450 are not supported in the medical record. The medical record only supports 1 unit of CPT code 70450. 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 two units of CPT 70450 provided on January 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated abutment and abutment supported crown for tooth #29 provided on February 24, 2020.You asked the Plan to pay for the prefabricated abutment and abutment supported crown for tooth #29. You say that the crown was a necessary solution. You say that you thought insurance would benefit 50% toward the services.The Plan denied your request. The Plan says the services are not covered benefits.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.Tooth #29 is not an anterior tooth. Therefore, we decided that the Plan does not have to pay for the prefabricated abutment and abutment supported crown for tooth #29 provided on February 24, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on March 25, 2020.You asked the Plan to waive the copayment for the emergency room visit. You say that you tried to go to your primary care provider's office first but were told to go the emergency room. You say you should not be responsible for the emergency room copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.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 $90 copayment for each Medicare-covered emergency room visit. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" 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 emergency room visit provided on March 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that thePlan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvemammography. You say that you have a history with a provider at this facility.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can receive this test from an in-network provider.Medicare rules say that plans can require enrollees to get carefrom 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 medical services to be provided by an out of network (OON) provider.