Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveGel-One.You asked the Plan to pre-approvethe Gel-One. You say that this is a repeat injection and not the first time getting the injection.The Plan denied your request. The Plan says the information submitted does not meet medical necessity guidelines for coverage. The plan says that the enrollee must have had previous treatment, contraindication, or intolerance to Orthovisc and Monovisc.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 carefullyreview the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Gel-One. Our reviewer says that the criteria for coverage of Gel-One have not been met. Our physician reviewer found the medical records do not indicate that the enrollee has tried and failed Orthovisc and Monovisc. Our physician reviewer found that the medical records do not indicate that these Plan required drugs would likely be less effective or likely to have adverseeffects 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 Gel-One have not been met.Therefore, we decided that the Plan does not have to pre-approveGel-One.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira for the enrollee.
You asked the Plan to pre-approve Humira. You say that Humira is a good fit for the enrollee. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered drugs.
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 Humira for the enrollee.
Benefits for Humira 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 pre-approve the medical services to be provided to the enrollee by
an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. You say that the requested provider has the technical
ability to perform the intricate surgery. The Plan denied your request. The Plan says the necessary clinical
expertise is available in the enrollee's 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 OON services. Therefore, we decided that the Plan does not have to pre-approve the
medical services to be provided to the enrollee by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay further for the services rendered to the enrollee on June 21, 2017.
You asked the Plan to pay further for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim has been paid at the maximum Medicare allowed amount.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has The Plan has paid the full Medicare allowed amount on this claim. Further payment cannot be determined until the current case is completed.. As the secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay further for the services rendered to the enrollee on June 21, 2017.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on November 4, 2019.
You asked the Plan to pay for the shoulder-elbow-wrist-hand orthosis (L3960). You say that the Plan should
pay this claim. The Plan denied your request. The Plan says the enrollee has a shoulder-elbow-wrist-hand
orthosis still under reasonable useful lifetime.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The file shows that the enrollee had a shoulder-elbow-wrist-hand orthosis (L3960) provided by a different
provider on April 13, 2018. The shoulder-elbow-wrist-hand orthosis (L3960) provided by a different provider
serves the same purpose as the shoulder-elbow-wrist-hand orthosis (L3960) at issue. Therefore, we decided that
the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on November 4, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Emergency Room Services (99284)
provided August 31, 2019 to September 4, 2019.
You asked the Plan to waive the copayment for the Emergency Room services. You say that the copayment
should be waived. The Plan denied your request. The Plan says the correct copayment was 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $90 copayment for Emergency Care.
The enrollee has been asked to pay a $90 copayment for the Emergency Room services. The Emergency Room
services fall within the Emergency Care benefit category. This means that the enrollee has been asked to pay
the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the
copayment for Emergency Room Services (99284) provided August 31, 2019 to September 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs access to physicians
on a daily basis, and needs respiratory therapy around the clock. The Plan denied your request. The Plan says
the enrollee's needs are being met in the current setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our physician
reviewer found that the enrollee was admitted and treated at the current acute care facility with acute
respiratory failure, pneumonia, and NSTEML. Mechanical ventilation was needed as well as antibiotics.
Current wound care, pulmonary support, and diuretics suggest at least a short-term need for acute care at the
current facility. However, the past few days, clinical response suggests this need would not likely be more than
25 days and continuing care are the current facility is most appropriate. Transfer to LTACH would not provide
any needed treatments not already being provided and covered in the current setting. Therefore, based on the
most recent records, this request for LTACH services will be considered not medically 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 29, 2019 to August 7, 2019 by an out of network provider.
You asked the Plan to pay for physical therapy. The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that there are in-network providers available.
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 the medical services provided on July 29, 2019 to August 7, 2019 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis, the knee orthoses and suspension
sleeves provided on February 1, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650), the knee orthoses (L1851) and suspension
sleeves (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan
says rules for telehealth services have not been met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis,
the knee orthoses and suspension sleeves provided on February 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 29, 2019 to the enrollee by an out of network (OON) provider.
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 services were rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The 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 the medical services provided on October 29, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rowasa for the enrollee.
You asked the Plan to pre-approve Rowasa. You say that the enrollee has tried and failed several medications. The Plan denied your request. The Plan says the medication is not covered under the medical benefit.
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 Rowasa for the enrollee.
Benefits for Rowasa 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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Gammagard for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that Gammagard is covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee is being treated for multiple myeloma. She has a low globulin level of 1 (normal 1.9-3.7) and has had a recent hospitalization for pneumonia. She is not immune to measles. The Medicare rules list multiple myeloma as a covered indication for Gammagard and the use is supported in the Medicare compendia. The Gammagard is reasonable and medically 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 these services have been met. Therefore, we decided that the Plan has to pre-approve Gammagard 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the darbepoetin alfa injection provided from March 4, 2019 to March 9, 2019.
You asked the Plan to waive the coinsurance for the injection. You say that you cannot afford this. 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 a 20% coinsurance for each Medicare-covered Part B drug. You have been asked to pay a 20% coinsurance for the injection. The injection falls within the Medicare-covered Part B drug 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 the darbepoetin alfa injection provided from March 4, 2019 to March 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a negative pressure would therapy pump (E2402).
You asked the Plan to pre-approve the negative pressure wound therapy pump. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this request is not medically reasonable and necessary
The Plan must follow Medicare rules. Medicare rules say that negative pressure wound therapy pumps and supplies will be denied as not medically reasonable and necessary once the equipment or supplies are no longer being used for the beneficiary, whether or not by the treating practitioner's order. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the negative pressure wound therapy pump have not been met. Specifically, the record indicates that the equipment was sent back in early February. Therefore, we decided that the Plan does not have to pre-approve a negative pressure would therapy pump (E2402).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the rollator purchased on September
12, 2019.
You asked the Plan to reimburse you for the rollator. You say that you needed a walker without delay and you
were not aware the provider was not certified with Medicare. The Plan denied your request. The Plan says you
obtained durable medical equipment from a provider who does not participate with Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items provided directly by a provider who is not eligible to take Medicare payment.
The item at issue in this appeal was provided by a provider not certified by Medicare. Therefore, we decided
that the Plan does not have to reimburse you for the rollator purchased on September 12, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on December 19, 2019.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a domiciliary, rest home visit provided on December 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat
exchanger provided on December 5, 2019.
You asked the Plan to pay for the perfusionist services. You say that the Plan should pay this claim. The Plan
denied your request. The Plan says this claim cannot be paid separately based on Medicare guidelines for
inpatient services. The Plan says that this claim should be submitted to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all
necessary covered services to the beneficiary either directly or under arrangements made with outside
providers.
This equipment was used during and after a surgical procedure by the facility. Payment for this service would
have been included under the facility claim. Payment to you for this service is the responsibility of the facility
or hospital. Based on this information, we decided that Medicare rules for coverage of the perfusionist services
have not been met. Therefore, we decided that the Plan does not have to pay for assembly and operation of
pump with oxygenator or heat exchanger provided on December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nutritional counseling referral.
You asked the Plan to pre-approve medical nutrition therapy services. You say that you would like reconsideration because you have recently gained weight without changing your diet. The Plan denied your request. The Plan says nutritional counseling for your diagnosis is not a covered benefit under your benefit package.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pre-approve a nutritional counseling referral.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve low dose CT scan for lung cancer screening for the
enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not medically necessary when you are less than 55 years old, and have no
quantified amount of tobacco exposure or abuse.
The Plan must follow Medicare rules. Medicare rules say that LDCT scans are covered only for enrollees
between 55-77 years old.
In this case, the enrollee under the age limit for this service. Based on this information, we
decided that Medicare rules for coverage of the scan have not been met. Therefore, we decided that the Plan
does not have to pre-approve low dose CT scan for lung cancer screening for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve a total electric hospital bed. You say that a total electric hospital bed is
medically necessary. The Plan denied your request. The Plan says Medicare does not cover total electric
hospital beds. The Plan also states you are under hospice election as of March 11, 2020, and that this type of
request must be submitted to Original 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. As you are currently on hospice status, this request should be submitted to Original
Medicare per the above guidelines. Therefore, we decided that the Plan does not have to pre-approve a total
electric hospital bed.