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

We decided that the Plan does not have to pre-approve Supartz (J7321).

You asked the Plan to pre-approve Supartz. You say that you would like this drug to be approved for the enrollee. The Plan denied your request. The Plan says the enrollee has not received the treatment with the requested targeted product in the past 365 days.

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 Supartz. Our reviewer says that Supartz (J7321) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial of the drug Orthovisc before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug. Our physician reviewer also found that there is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz (J7321).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the eye exam provided on November 7, 2020.
You asked the Plan to waive the copay for the eye exam. You say that the glaucoma screening is covered in full. The Plan denied your request. The Plan says the services were diagnostic in nature.
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 $45 copay for services to diagnose and/or treat a disease or condition of the eye. The file shows that you received a diagnostic exam for the treatment of your glaucoma condition. You have been asked to pay a $45 copay for the eye exam. The service falls within the vision 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 copay for the eye exam provided on November 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81401, 81403, 81404, 81405, 81406, 81407, 81408) provided on February 10, 2020.
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was billed with an incorrect POS.
The Plan must follow Medicare rules. Medicare rules say that that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The services at issue were billed with POS 81 for an independent laboratory, but the records show that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81401, 81403, 81404, 81405, 81406, 81407, 81408) provided on February 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the enhanced materials (D5899 x 2) provided on October 16, 2020.
You asked the Plan to pay for the dental services. You say that you got new dentures and they do not fit properly. You say that they are unusable. You say that you were advised that because you do not have any bone in your gum, you need to use a denture adhesive seal. You say that these products do not work. You also say that the dentist advised you need implants. The Plan denied your request. The Plan says the enhanced materials are not listed as covered services. The Plan also says that any services not listed are not covered.
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 enhanced materials (D5899 x 2) provided on October 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two periodontal scalings and root planings (D4342 x2) and preventive procedure (D1999).

You asked the Plan to pay for the scalings and planings and preventive procedure. You say that you believe these services should be covered. The Plan denied your request. The Plan says these services are not covered.

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 two periodontal scalings and root planings (D4342 x2) and preventive procedure (D1999).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport provided on October 30, 2020.
You asked the Plan to pay for the ambulance transport. You say that transport by ambulance was medically
necessary. The Plan denied your request. The Plan says the services are not covered.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
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 the ambulance transport. Our reviewer says
that transport by ambulance was not medically necessary. Our physician reviewer found the review has
determined that the documentation did not support that other means of transport (such as stretcher van,
wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this enrollee on 10/30/20.
The documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining
equipment that only a fully equipped ambulance can provide for safe transport on 10/30/20. The
documentation did not support that the ambulance transport on 10/30/20 was medically reasonable and
necessary 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 ambulance transport have not been met. Therefore, we decided that the Plan
does not have to pay for the ambulance transport provided on October 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiomyopathy risk factor screening (81286, 81404, 81407, 81408, 81479) provided on July 22, 2020.
You asked the Plan to pay for cardiomyopathy risk factor screening. You say that this was medically necessary. The Plan denied your request. The Plan says this testing is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of cardiomyopathy risk factor screening have not been met. Therefore, we decided that the Plan does not have to pay for cardiomyopathy risk factor screening (81286, 81404, 81407, 81408, 81479) provided on July 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve SNF care. You say that an inpatient skilled nursing facility admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an inpatient skilled nursing facility admission.

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 an inpatient skilled nursing facility admission is not medically necessary. Our physician reviewer found that you do not have documented skilled nursing or skilled therapy needs. You are consistently ambulating more than one hundred feet and tending to activities of daily living with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care.

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 an inpatient skilled nursing facility (SNF) admission.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the PBRT services (CPT code 77525).

You asked the Plan to pre-approve the PBRT services. You say that the services are necessary. The Plan denied your request. The Plan says a review of the current medical literature indicates that the standard of care for radiation therapy for breast cancer is standard radiation therapy including Intensity modulated radiation therapy (IMRT).

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 PBRT services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found your case is somewhat unique in that you have not undergone resection of your primary cancer necessitating dose escalation, but it is not evident that proton therapy is needed to achieve that. Thus, our physician reviewer's decision is unfavorable as proton therapy would not be "furnished in accordance with accepted standards of medical practice."

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 PBRT services have not been met. Therefore, we decided that the Plan does not have to pre-approve the PBRT services (CPT code 77525).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the diagnostic radiology services rendered on August 26, 2020.
You asked the Plan to waive the copayments for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayments were 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 $155 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility.
Review of the file shows that you received three transcranial Doppler studies of the intracranial arteries on August 26, 2020. You have been asked to pay a $155 copayment per study for these services, for a total of $465. These services fall within the Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The file shows that you received a duplex scan of the aorta on August 26, 2020. Per the contract with the Plan, there is a $155 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility. However, the Medicare allowed amount for these services was $117.67. Given that the allowed amount was less than the $155 copayment, you have been asked to pay $117.67 for these services.
The file shows that you received a duplex scan of the extracranial arteries on August 26, 2020. Per the contract with the Plan, there is a $155 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility. However, the Medicare allowed amount for these services was $124.71. Given that the allowed amount was less than the $155 copayment, you have been asked to pay $124.71 for these services.
The total amount you have been asked to pay for these services is $707.38. 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 copayments for the diagnostic radiology services rendered on August 26, 2020.
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 services. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation does not show that three or more daily injections of insulin are required.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee is using insulin once a day. The required elements of the local coverage determination are not satisfied. Therefore, the requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99199) and a blood pressure monitor (A4670) provided outside of the United States.

You asked the Plan to pay for physician services and a blood pressure monitor. You say that your primary care physician would not see you in person, so you had to go to outside of the United States to receive care. The Plan denied your request. The Plan says these services are not covered.

The Plan must follow Medicare rules. Medicare rules say that with limited exceptions, items and services furnished outside the United States are excluded from coverage.

We looked at the file and Medicare rules. The services at issue were provided outside of the United States. Based on this information, we decided that Medicare rules for coverage of physician services and a blood pressure monitor have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99199) and a blood pressure monitor (A4670) provided outside of the United States.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the dental crown (D6750).

You asked the Plan to pay for the dental crown. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says that the services are not covered.

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.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided sufficient documentation in support of their denial. The Plan denied payment for the dental crown with code D6750 on tooth # 26 because the enrollee met their out of pocket max. However, the Plan provided no documentation verifying this. Therefore, we decided that the Plan has to pay for the dental crown (D6750).

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
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 the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the current evidence based medical guideline and peer reviewed literature do not fully support the requested spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. The services are therefore not reasonable or 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 not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.
You asked the Plan to pre-approve SI joint injection. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the record does not include advanced imaging showing the SI joint is inflamed or swollen.
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 SI joint injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found advanced imaging should be obtained prior to this proposed intervention. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SI joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp, 300 mcg/ml vial.

You asked the Plan to pre-approve Aranesp. You say that transfusions have made the enrollee's ferritin levels
dangerously high. You say that the Exjade used to treat the rising ferritin levels make the enrollee feel terrible.
You also say that the enrollee has responded to EPO treatment in the past. The Plan denied your request. The
Plan says our diagnosis is not covered under the National Coverage Determination (NCD) criteria for Medicare
Part B. The Plan also says that this medication is not recommended when your erythropoietin (EPO) level is
over 500 mU/ml.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
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 Aranesp. Our reviewer says that
Aranesp is not medically necessary. Our physician reviewer found the requested use of Aranesp FDA-approved
for your diagnosis. The reviewer found that requested use of Aranesp is not supported by one of the major drug
compendia or by clinical research that appears in a CMS-approved medical journal. The reviewer found that
the requested use is not listed as indicated, not supported or not recommended in any of the compendia.
Therefore, the reviewer found that the requested drug, Aranesp, is not medically reasonable or 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 Aranesp have not been met. Therefore, we decided that the Plan does not have
to pre-approve Aranesp, 300 mcg/ml vial.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound of the head and neck.

You asked the Plan to waive the copayment for the ultrasound. You say that you should not have to pay a copayment for this service since it was part of your wellness visit. The Plan denied your request. The Plan says ultrasounds are not considered part of a wellness visit, so this copayment was charged 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 $40 copayment for diagnostic procedures and tests in a specialist's office.

You have been asked to pay a $40 copayment for the ultrasound. The ultrasound falls within the diagnostic procedures and tests in a specialist's office 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 ultrasound of the head and neck.