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

We decided that the Plan has to pre-approve Zinplava.
You asked the Plan to pre-approve Zinplava. The Plan denied your request. The Plan says that the drug is not being used in combination with an antibacterial therapy.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Zinplava. Our physician reviewer found that the enrollee has a history of diarrhea with Clostridium difficile infection. There is documentation that Zinplava is FDA-approved for the enrollee's diagnosis. The requested use of Zinplava is not listed as not indicated, not supported or not recommended in any of the compendia. At the time of the request, the provided records indicate that the enrollee would be on Dificid 200 mg twice daily. Given that the enrollee would be on Dificid twice daily, the documentation does support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Zinplava have been met. Therefore, we decided that the Plan has to pre-approve Zinplava.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 6, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on July 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a
participating provider on February 1, 2021.

You asked the Plan to waive the copayment for an outpatient surgery. You say that this copayment is too high.
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 $550
copayment for outpatient surgery/in-network.

You have been asked to pay a $550 copayment for an outpatient surgery. The injection that was provided is
considered an outpatient surgery; therefore, the correct copayment has been applied. An outpatient surgery falls
within the outpatient surgery/in-network 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 outpatient surgery provided by a participating provider on February 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on September 4, 2020.
You asked the Plan to pay for the laboratory services. You say that payment should be reconsidered. The Plan denied your request. The Plan says prior authorization was required but not 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. Therefore, we decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on September 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten additional physical therapy visits for the enrollee.
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary.] The Plan denied your request. The Plan says a home exercise program has been implemented.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee can transition to a home exercise program. 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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten additional physical therapy visits for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667).
You asked the Plan to pre-approve a pneumatic compression device. You say that the PCD is medically necessary. The Plan denied your request. The Plan says there is no record of the required four-week trial of conservative therapy.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve blood glucose testing supplies to allow for testing eight times per day.
You asked the Plan to pre-approve the requested amount of testing supplies. You say that you are suffering from hypoglycemia for a procedure that took place, and you need this amount of supplies to be able to regulate your blood glucose levels. The Plan denied your request. The Plan says this amount of testing supplies is not medically necessary for your condition. Testing three times per day is sufficient to meet your needs.
The Plan must follow Medicare rules. Medicare covers blood glucose monitors and testing supplies only for enrollees with diabetes. In this case, you do not have a diagnosis of diabetes. Your Plan has elected to cover testing supplies to allow for three times per day testing. There is no provision in Medicare rules which would require them to cover more than this. Therefore, we decided that the Plan does not have to pre-approve blood glucose testing supplies to allow for testing eight times per day.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213).
You asked the Plan to pre-approve the dental item. You say that your dentures no longer work. You say that they hurt your mouth. You also say that you have difficulty speaking and eating. The Plan denied your request. The Plan says coverage for dentures is limited to once every 60 months. The Plan also says that the frequency limit has been reached.
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 and dentures are listed as covered, the frequency limit has been reached. The record shows that the Plan paid for a partial upper denture that you received on October 12, 2018. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213).
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for a psychotherapeutic telehealth visit (90837) on January 22, 2021.
You asked the Plan to pay for a psychotherapeutic telehealth visit. You say that the services at issue were a necessity for the enrollee's care. The Plan denied your request. The Plan says that rules for out of network telehealth care have not been met.
The Plan must follow Medicare rules. Medicare rules say that PPO plans must cover all Medicare-covered services out-of-network but may apply higher cost sharing. Medicare has expanded telehealth coverage to allow all providers who may bill Medicare for professional services to be paid for telehealth services. The Plan at issue is a PPO and cannot deny coverage for certain out-of-network services, such as telehealth. The PPO plan is also not allowed to impose prior authorization requirements on covered out of network care. As such, we find that the Plan has not provided any valid denial rationale to support non-payment of this claim. Therefore, we decided that the Plan has to pay for a psychotherapeutic telehealth visit (90837) on January 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a chair lift (E1399).
You asked the Plan to pre-approve the chair lift. You say that the chair lift is medically necessary. The Plan denied your request. The Plan says this is not a covered item.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a chair lift (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision care services (V2750, V2744, V2020) received February 1, 2021 from the out-of-network provider.
You asked the Plan to pay for the vision care services (V2750, V2744, V2020). You say that the in-network provider did not have glasses you wanted. The Plan denied your request. The Plan says any benefits received at a non-network provider not covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when received from a network provider. We looked at the file and the Plan's rules. The requested services were obtained out-of-network. Your benefit with the Plan does not include coverage for services received out-of-network. Based on this information, we decided that the Plan's rules for coverage of the vision care services (V2750, V2744, V2020) have not been met. Therefore, we decided that the Plan does not have to pay for the vision care services (V2750, V2744, V2020) received February 1, 2021 from the out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided on December 4, 2020 by an out of network (OON) provider.
You asked the Plan to pay for hospital services. You say that you were told prior authorization was not needed. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider.
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 hospital services provided on December 4, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that you would like reconsideration because the
requested drug is medically necessary. The Plan denied your request. The Plan says that it is unknown if there
has been a trial of 3 months of treatment with non-pharmacologic therapy, non-steroidal anti inflammatory
drugs and/or aspiration.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that the
requested drug is medically necessary for this member. Our physician reviewer found the member is
symptomatic, has a clinical diagnosis supported by radiologic evidence of osteoarthritis of the knee, has failed
at least three months of conservative therapy and has failed to respond to aspiration of the knee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Euflexxa have been met. Therefore, we decided that the Plan has to pre-approve
Euflexxa.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee has edema and needs physical therapy (PT) and occupational therapy (OT) to be in good shape for surgery and get well to go home. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for urinary tract infection. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care.
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that the requested wheelchair is medically necessary for your condition. The Plan denied your request. The Plan says they have in-network providers that are able to provide you with the equipment you need.

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 group 3 power wheelchair and accessories to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 Sensor.
You asked the Plan to pre-approve a FreeStyle Libre 2 Sensor. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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. 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 FreeStyle Libre 2 Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 2 Sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the frames (V2020) and lenses (V2199).

You asked the Plan to pre-approve the frames (V2020) and lenses (V2199). You say that the Plan should pay for the frames and lenses. The Plan denied your request. The Plan says your 2021 supplemental benefit does not include coverage of frames or lenses.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when one routine eye exam every year.

We looked at the file and the Plan's rules. Your supplemental benefit does not include coverage of frames and lenses. Therefore, we decided that the Plan does not have to pre-approve the frames (V2020) and lenses (V2199).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on December 14. 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the Covid executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.
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 14, 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 services provided on December 14. 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bite wing x-rays (D0274) provided on March 11, 2021.

You asked the Plan to pay for bite wing x-rays. You say that you feel the Plan is not very specific about which x-rays are covered, and as a result should pay for the bite wing x-rays. The Plan denied your request. The Plan says bite wing x-rays are not covered by your dental benefit. The x-rays that are covered are listed in the contract with specific procedure codes.

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 bite wing x-rays (D0274) provided on March 11, 2021.