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

We decided that the Plan does not have to pre-approve supplies for a therapeutic CGM (K0553).
You asked the Plan to pre-approve supplies for a CGM. You say that it is your goal to lower your A1C and not become insulin-dependent. The Plan denied your request. The Plan says rules for approval have not been met because you are not using insulin.
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 you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of supplies for a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve supplies for a therapeutic CGM (K0553).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient behavioral health care provided from July 11, 2020, to July 13, 2020.
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the enrollee no longer required inpatient care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient care. Our reviewer says that the requested inpatient care was not medically reasonable and necessary in this case. Our physician reviewer found that this enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of July 11, 2020, to July 13, 2020, as the enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats the safety and has been participating in therapy. 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 care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient behavioral health care provided from July 11, 2020, to July 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor (CGM). You asked the Plan to pre-approve CGM. You say that you are appealing with supporting medical records. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for a continuous glucose monitor. 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 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. Based on this information, we decided that Medicare rules for coverage of CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve lumbar/thoracic nerve block injection (Ganglion Impar).

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says that there is little evidence to show that this procedure is safe.

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 injection. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found a Ganglion impar block is the standard of care for the diagnosis and treatment of the sympathetic component of pelvic pain. You have had a successful block in the past. The request 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 the injection have been met. Therefore, we decided that the Plan has to pre-approve lumbar/thoracic nerve block injection (Ganglion Impar).

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 pay for the eye refraction you received.

You asked the Plan to pay for the refraction. The Plan denied your request. The Plan says this is not a covered benefit.

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 provided during a routine eye exam.

We looked at the file and the Plan's rules. The refraction was provided during a medical eye exam, and not during a routine exam. The Plan only covers refractions provided during a routine eye exam. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction you received.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by an outpatient surgery on October 7, 2020. You asked the Plan to waive the copayment for skin growth removal. You say that you thought this was just a normal office visit. 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 $200 copayment for outpatient surgery. You have been asked to pay $191.86 which is less than your copayment amount of $200 for skin growth removal. The services that were provided are considered an outpatient surgery. When providers are associated with a hospital, outpatient hospital copayments can be applied; therefore, the correct copayment has been applied. Skin growth removal falls within the outpatient surgery 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 outpatient surgery on October 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Coflex Interlaminar/Interspinous Process Stabilization for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of the Coflex device in the setting of lumbar spinal stenosis and lumbar radiculopathy have not been demonstrated in the peer-reviewed literature.

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 requested services are not considered medically reasonable and necessary in this case. The Coflex device remains experimental. More research is needed to show safety and efficacy. There is no documented instability on flexion extension x-rays and hardware not needed. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.

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 Coflex Interlaminar/Interspinous Process Stabilization for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on June 10, 2019.
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the corrected claim was not filed timely per Medicare guidelines.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a corrected claim for the psychiatric diagnostic evaluation was not filed until October 8, 2020. This means that more than one calendar year from the date of service had passed before a corrected claim was filed. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on June 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Life Alert.
You asked the Plan to pre-approve a Life Alert. You say that you need this device to be safe. The Plan denied your request. The Plan says this device is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules also say that telephone alert systems will be denied because these are emergency communications systems and do not serve a diagnostic or therapeutic purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a Life Alert.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital services billed for care.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the service has exceeded the maximum allowable units per date of service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and the rules. The records show that the code at issue was previously paid for the same date at issue. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital services billed for care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided to the enrollee by an out-of-network provider on October 19, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. 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 the vision services provided to the enrollee by an out-of-network provider on October 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic screening services (81401, 81403, 81404, 81405, 81406, 81407, 81408) provided on April 18, 2020.
You asked the Plan to pay for genetic screening services. You say that this was medically necessary. The Plan denied your request. The Plan says this was a non-covered screening service.
The Plan must follow Medicare rules. Medicare rules say that screening services such as pre-symptomatic genetic tests and services used to detect an undiagnosed disease or disease predisposition are not a benefit and are not covered. We looked at the file and Medicare rules. The record shows that the testing at issue was used to detect a disease predisposition. Based on this information, we decided that Medicare rules for coverage of genetic screening services have not been met. Therefore, we decided that the Plan does not have to pay for genetic screening services (81401, 81403, 81404, 81405, 81406, 81407, 81408) provided on April 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift.
You asked the Plan to pre-approve a stair lift. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says stair lifts are not covered by Medicare or the Plan.
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 stair lift.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for the cardiac services provided from May 30, 2019, to May 31, 2019.
You asked the Plan to pay for the cardiac services. You say that this was not a research study but pacemaker procedures. The Plan denied your request. The Plan says that this was a research study that was not approved.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the cardiac services by a contract provider. The file does not show that the Plan provided notice that the cardiac services would not be covered. Under Medicare rules, this means the cardiac services is considered approved by the Plan. Therefore, we decided that the Plan has work with the provider to have the claims submitted properly for the cardiac services provided from May 30, 2019, to May 31, 2019.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided by an out-of-network provider on November 17, 2020.
You asked the Plan to pay for physician services. You say that the provider should be reimbursed for the services rendered. 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 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 physician services provided by an out-of-network provider on November 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for orthopedic surgery (27822, 27829) provided on July 15, 2020.
You asked the Plan to waive the coinsurance for orthopedic surgery. You say that you met your out-of-pocket maximum in November and should not be charged. The Plan denied your request. The Plan says this processed 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 outpatient surgery services. You have been asked to pay a $289.60 coinsurance for orthopedic surgery ($1,447.97 allowed amount x 20% = $289.60). While the record shows that you did meet your out-of-pocket maximum in November, these services were provided in July and the out-of-pocket maximum had not been met prior to the processing of this claim. 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 orthopedic surgery (27822, 27829) provided on July 15, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve 48 additional narrow band ultra-light therapy treatments.
You asked the Plan to pre-approve additional narrow band ultra-light therapy treatments. You say that the requested additional narrow band ultra-light therapy treatments are medically necessary. The Plan denied your request. The Plan says that the requested additional narrow band ultra-light therapy treatments are not medically necessary.
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 additional narrow band ultra-light therapy treatments. Our reviewer says that the requested additional narrow band ultra-light therapy treatments are medically necessary. Our physician reviewer found the enrollee has disseminated psoriasis, BSA>30%, requiring systemic therapy. His concurrent hematologic disease does not allow the use of biologics that he used in the past. Therefore, the narrow band UV that provides for some improvement should be continued for the requested 60 sessions. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional narrow band ultra-light therapy treatments have been met. Therefore, we decided that the Plan has to pre-approve 48 additional narrow band ultra-light therapy treatments.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 7, 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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 7, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 17, 2020.
You asked the Plan to pay for the lab services. You say that the claim has not been paid in full or under the terms of the contract for the services provided to the enrollee. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation with an out-of-network provider.
You asked the Plan to pre-approve the consultation. You say that this doctor specializes in ankles and feet. You
say that your primary doctor referred you after seeing the podiatrist. The Plan denied your request. The Plan
says in-network providers are 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 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
the consultation with an out-of-network provider.