Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on August 7, 2019 to August 9, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you should not have to pay for this because you felt like the Provider was negligent during the surgery. 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 $320 copayment per day for days 1-5. There is a $0 copayment per day for days 6-90 for inpatient hospital care. You have been asked to pay a $320 copayment per day for days 1-2 for an inpatient hospital stay. The total amount you are being asked to pay is $640 ($320 x 2 days = $640). An inpatient hospital stay falls within the inpatient hospital 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 an inpatient hospital stay provided on August 7, 2019 to August 9, 2019.
We note your complaint about the doctor performing your surgery. Your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a sacroiliac joint injection (27096).
You asked the Plan to pre-approve a sacroiliac joint injection (27096). You say that the requested sacroiliac
joint injection is medically necessary. The Plan denied your request. The Plan says that the requested sacroiliac
joint injection is 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 a sacroiliac joint injection (27096). Our
reviewer says that the requested sacroiliac joint injection is medically necessary. Our physician reviewer found
the enrollee has chronic low back pain. She had epidural steroid injections to address radicular pain. She
continues to have localized Right SI joint pain. Physical exam documents SI Joint dysfunction. She is currently
participating in a physician-directed home exercise program. The enrollee has trialed gabapentin, NSAIDS,
heat/ice, physical therapy, TENS, and activity modification. The request is for a diagnostic SI joint injection.
The enrollee has symptoms and physical exam findings of Sacro-ilitis. She has failed conservative therapy. The
procedure is medically reasonable and necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a sacroiliac joint injection (27096) have been met. Therefore, we decided that
the Plan has to pre-approve a sacroiliac joint injection (27096).
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture.
You asked the Plan to pre-approve the complete maxillary denture. You say that you already had a maxillary tooth removed because it was infected. You also say that you will require a complete maxillary denture because your last remaining upper tooth will also need to be removed. The Plan denied your request. The Plan says NC is a non-covered service. The Plan also says that this service is not a covered benefit for this plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for hospice (G0299), physical therapy services performed in hospice (G0151), occupational therapy services performed in hospice (G0152), and skilled nursing services performed in hospice (G0300) provided on September 25, 2019 to October 3, 2019 by out of network provider.
You asked the Plan to pay for hospice services. You say the patient had recently moved. When you admitted this patient, you did not know her insurance did not have out-of-network coverage. You are requesting reimbursement from the Plan for the rendered services. When you were on the Plan's website to apply for pre-authorization, the Plan did not flag you that this policy did not have out-of-network coverage. The Plan denied your request. The Plan says enrollees must receive their care from a network provider. In most cases, care received from an out-of-network provider will not be covered. There are three exceptions: 1) The plan covers emergency care or urgently needed services that an enrollee can get from an out-of-network provider; 2) if the enrollee needs medical care that Medicare requires the plan to cover and the providers in the network cannot provide this care, the enrollee can get this care from an out-of-network provider; and 3) the plan covers kidney dialysis services that an enrollee can get at a Medicare-certified dialysis facility when they are temporarily outside the plan's service area.
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 has network providers available who can provide 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 hospice (G0299), physical therapy services performed in hospice (G0151), occupational therapy services performed in hospice (G0152), and skilled nursing services performed in hospice (G0300) provided on September 25, 2019 to October 3, 2019 by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulicity injectors.
You asked the Plan to pre-approve the Trulicity. You say that this is the only medication that has been able to control the enrollee's blood sugars. The Plan denied your request. The Plan says this medication is for self-injection and cannot be covered by Medicare 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 Trulicity injectors.
Benefits for the Trulicity 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: Favorable

We decided that the Plan has to approve the acute inpatient admission requested on May 9, 2020.You asked the Plan to approve the inpatient admission. You say that the enrollee requires inpatient care due to her severe anxiety causing respiratory and cardiac issues. She is being evaluated for possible psychiatric admission due to her condition.The Plan denied your request. The Plan says that the enrollee does not require inpatient care for anxiety.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 approve the inpatient admission. Our reviewer says that the documentation supports that the criteria for inpatient admission are met in this case. Our physician reviewer found the enrollee was recently discharged after a hospitalization due to COVID-19. She was in the hospital for 23 days, unclear if intubated/sedated during that stay. She left the hospital and returned in 24 hours due to inability to access prescription for hydroxyzine for anxiety. She has a history of DM, COPD, ESRD on HD and presented with acute anxiety with SOB/tachycardia with elevated D-dimer. Evaluation revealed tachycardia and an elevated D-dimer . She was admitted. CT of the chest revealed LUL mass. She was evaluated by IR Pulmonary and had a PET scan. She was stabilized on medical therapy and remained in the hospital until at least 5/12. The review has determined that the record did show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.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 inpatient admission have been met.Therefore, we decided that the Plan has to approve the acute inpatient admission requested on May 9, 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the first 15 minutes of intravenous moderate (conscious) sedation/analgesia (code D9239) and each subsequent 15 minute increment of intravenous moderate (conscious) sedation/analgesia (code D9243).
You asked the Plan to pre-approve the sedation/analgesia services. You say that your insurance company told you to appeal so that these services would be covered. The Plan denied your request. The Plan says Medicare does not cover these services and therefore this service is not covered by your plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the first 15 minutes of intravenous moderate (conscious) sedation/analgesia (code D9239) and each subsequent 15 minute increment of intravenous moderate (conscious) sedation/analgesia (code D9243).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Euflexxa injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan's preferred viscosupplements are Orthovisc and Monovisc and don't require prior authorization.
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 injection. Our reviewer says that the requested drug is not medically reasonable and necessary, and did not follow step therapy guidelines. Our physician reviewer found there is no indication of a trial and failure of Monovisc. The provided medical records do not indicate that Monovisc 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Euflexxa injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a podiatrist. on December 23, 2019.You asked the Plan to waive the copayment for an ultrasound. You say that you already paid your office visit copayment. You say that you should not be charged again. 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 $50 copayment for outpatient diagnostic tests/diagnostic procedures and tests. You have been asked to pay a $50 copayment for an ultrasound. When additional services are provided during an office visit, additional copayments can be applied; therefore, the correct copayment has been applied. An ultrasound falls within the outpatient diagnostic tests/diagnostic procedures and 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 copayment for an ultrasound provided by a podiatrist on December 23, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for an x-ray of the head (70350) provided on May 8, 2019.
You asked the Plan to pay for an x-ray of the head. You say that this was medically necessary. The Plan denied your request. The Plan says that this is not a covered service.
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only when the condition or symptom is medical in nature. The treatment must also be medically 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 pay for an x-ray of the head. Our reviewer says that this service was both medical in nature and medically necessary. Our physician reviewer found the documentation does show that the x-ray was being used for diagnosis of a medical condition affecting the tempormandibular joints. You presented with increasing pain in the jaws on eating/biting, clicking and popping of the jaws, and consistent pain during the day. These symptoms were consistent with some dysfunction of the temporomandibular joints and diagnostic x-rays are appropriate to assess the bony structures, spacing between the head of the condyle and the cranial fossa and general bony structures of the jaws in this manner. 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 x-ray of the head have been met. Therefore, we decided that the Plan has to pay for an x-ray of the head (70350) provided on May 8, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve perioral endoscopic myotomy (POEM) for the enrollee.You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says that an incorrect CPT code was used in this request, and this is considered experimental and investigational with no randomized, placebo-controlled studies.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the he enrollee has had symptoms of dysphagia and emesis of liquids and solids for over one year. His Eckardt score was 11-12/12. POEM is considered a primary treatment for type I and II achalasia, as an alternative to pneumatic dilation and surgical myotomy. POEM is considered a preferred treatment for type III achalasia. The documentation supports that the POEM procedure is medically reasonable and necessary for the enrollee in this case.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 services have been met.Therefore, we decided that the Plan has to pre-approve perioral endoscopic myotomy (POEM) for the enrollee.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.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a continuous glucose monitoring system.
You asked the Plan to pre-approve the continuous glucose monitoring system. You say that a Dexcom G6 is medically appropriate and necessary. You say that the enrollee's medical history, prognoses, and treatment rationale support the need for the requested device. The Plan denied your request. The Plan says that the most recent records from the enrollee's physician indicate that he is on three set doses of insulin per day and does not adjust based on blood sugar readings. The Plan says that a continuous glucose monitor is not reasonable and necessary and will not be covered by insurance.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. 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 continuous glucose monitoring system. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee is taking 4 shots per day, is checking levels 4 times a day, and is adjusting doses. The enrollee will be adjusting his insulin doses and food intake according to blood glucose levels once he has a CGM. The A1c of 5.7% is low enough to be consistent with frequent low blood glucose levels. The enrollee would be a good candidate for the Dexcom CGM. 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 continuous glucose monitoring system have not been met. Therefore, we decided that the Plan has to pre-approve a continuous glucose monitoring system.
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.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve visual field testing (92083).
You asked the Plan to pre-approve visual field testing. You say that this provider saw something concerning during your eye exam. The Plan denied your request. The Plan says that per the Medicare guidelines, visual field testing is covered when it is performed by an ophthalmologist. This provider is an optometrist, not an ophthalmologist.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Diagnostic tests may only be ordered by treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements). The patient's medical record must contain documentation that fully supports the medical necessity for services. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, there was no documentation to show that Medicare will only cover visual field testing when provided by an ophthalmologist. The LCD language quoted by the Plan was not found within the LCD cited by the Plan. There was no information to show that the requested provider is practicing outside of the scope of his license. There were also no medical records provided to show that by treating you, the requested provider would be providing services outside of the scope of his license. The Plan did not provide alternate providers available to see you in a reasonable period of time. Based on the information provided, the documentation is not substantiated, and we must find in your favor. Therefore, we decided that the Plan has to pre-approve visual field testing (92083) with the requested provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orencia 250mg vial 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 this drug is subject to step therapy. 
 
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 there is no evidence of a trial and failure of Simponia Aria. While it is noted that this enrollee was previously on Orencia with great benefit, the documentation does not support that Simponia Aria would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 
 
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 Orencia 250mg vial for the enrollee.