Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60 mg/ml syringe.
You asked the Plan to pre-approve Prolia 60 mg/ml syringe. You say that the prior authorization has been denied and you are requesting reconsideration. The Plan denied your request. The Plan says Medicare coverage criteria has been met.
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 Prolia 60 mg/ml syringe. Our reviewer says that this enrollee has not meet the Medicare coverage criteria. Our physician reviewer found the plan outlines the use of the drug must be prescribed for the diagnosis of osteoporosis with a history of an osteoporotic fracture or failure or contraindication to zoledronic acid. Documentation does not support the enrollee has trialed a zoledronic acid. The documentation does outline contraindications or reasons these medications were not considered. Without the support of the documentation, Prolia is not approved as step criteria is not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia 60 mg/ml syringe have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia 60 mg/ml syringe.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Travoprost eye drops for the enrollee.
You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Travoprost eye drops for the enrollee.
Benefits for this drug 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two additional extractions provided on June 11, 2019.
You asked the Plan to pay for the two additional extractions. You say that you contacted the Plan prior to the services being rendered and were told that they would be 100% covered. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has been exceeded.
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, extractions are limited to two procedures per calendar year. The record shows that you received four extractions on June 11, 2019, two of which were covered by the Plan, and your extractions benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the two additional extractions provided on June 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continued endocrinology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON endocrinology services. You say that the enrollee needs to continue with this provider in order maintain regular Prolia injections. The Plan denied your request. The Plan says one transitional visit has been approved to avoid interrupting a scheduled treatment. However, visits beyond this must be provided in-network.
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 continued endocrinology services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says that the enrollee's condition does not require complex rehab, or medical services. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 physician reviewer found that the enrollee was admitted to acute care after collapsing. The enrollee has sustained a new stroke and has physical and cognitive impairments. There would be an expected need to modify the enrollee's treatment in order to maximize her capacity to benefit from rehabilitation. Physician supervision at an acute rehabilitation level of care is required. She requires physical therapy for mobility, occupational therapy for remaining activities of daily living and adaptive equipment, and speech therapy for cognition and communication. The enrollee's medical conditions appear stable and she is participating in the treatments being provided. She would be expected to be able to fully participate and benefit from the required intensity of an acute rehabilitation therapy program. The enrollee has therapy and medical needs that meet criteria for acute level rehabilitation. Care at a lower level would not effectively meet her rehabilitation needs. 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 been met. Therefore, we decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluoride carriers.
You asked the Plan to pre-approve fluoride carriers. 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. 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 fluoride carriers. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found fluoride trays, while of benefit in aiding in reducing the loss of teeth from dental decay following irradiation of the jaws and neck region, are not a covered service under Medicare as it relates directly to the care of teeth, despite the additional care being necessitated by the removal of a tumor, a covered service. There are no preventive service allowances for fluoride application, or the fabrication of fluoride holding trays for use with a prescription paste. The other provisions for basic services and major restorative under the plan also do not provide for the fabrication of trays for the requested purposes. Given the Policy provisions, there is no finding of necessity under the Plan for the requested procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of fluoride carriers have not been met. Therefore, we decided that the Plan does not have to pre-approve fluoride carriers.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for out-of-network home health services provided on August 28, 2019.
You asked the Plan to waive the cost-sharing for home health services. You say that you should not be charged for these services. The Plan denied your request. The Plan says these services 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 a $975 deductible for out-of-network services and a 30% coinsurance for out-of-network home health services. You have been asked to pay $11048.44 for out-of-network home health services. $975 of this charge is the deductible. This cost sharing is a contractual obligation that had not been met at the time home health services was received on August 28, 2019. The remaining $73.44 is your coinsurance ($244.80 remaining allowed amount x 30% = $73.44). 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 cost-sharing for out-of-network home health services provided on August 28, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Reclast infusion provided on August 7, 2019.
You asked the Plan to waive the coinsurance for the Reclast infusion. You say that you did not receive the infusion therapy. The Plan denied your request. The Plan says that you must pay 20% coinsurance for Medicare part B drugs.
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 Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for the Reclast infusion. The Reclast infusion falls within the Medicare Part B prescription drugs 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 Reclast infusion provided on August 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
You asked the Plan to pre-approve the inpatient psychiatric hospital services. You say that the records provided support the care in dispute. The Plan denied your request. The Plan says the records provided do not show that the enrollee's needs could not be met at a less restrictive outpatient level of 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 pre-approve the inpatient psychiatric hospital services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on February 14, 2020 with Bipolar Disorder Type I Current Episode of Manic.
Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time as he did not have dangerousness to self or others, delusions, auditory or visual hallucinations and was not showing any aggressive behavioral issues. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as he did not have dangerousness to self or others, perceptual disturbance including auditory or visual hallucinations. This enrollee does not appear to require inpatient mental health treatment as he was not a danger to himself or others and was cooperative and compliant. It did not appear that active treatment was taking place. It does not appear that the services requested are reasonably expected to improve the enrollee's condition or for the purpose of diagnosis. 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 psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 13, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extended use battery for an Inogen portable oxygen concentrator.
You asked the Plan to pre-approve a portable oxygen concentrator (POC) extended use battery. You say that the enrollee is dependent on oxygen and requires an extended battery due to a busy life. The Plan denied your request. The Plan says the enrollee was provided a POC to meet the need for supplemental oxygen and neither Medicare nor the Plan cover extended use batteries.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Equipment that is presumptively non-medical in nature and used primarily and customarily for a non-medical purpose, even though the item may have some remote medically-related use, is not considered DME. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Medicare will not pay separately or make any additional payment for precautionary equipment. Therefore, we decided that the Plan does not have to pre-approve an extended use battery for an Inogen portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for hip orthoses (L1686 and L2624) provided on September 13, 2019.
You asked the Plan to pay for the hip orthoses. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says evidence of an established relationship between the member and the ordering physician was not discovered.
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 hip orthoses (L1686 and L2624) provided on September 13, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services provided to the enrollee by the contracted provider on September 11, 2019.
You asked the Plan to pay for the services. You say that the enrollee has no contract over what diagnosis codes are billed. The Plan denied your request. The Plan says that services required by a third party are not covered.
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. The enrollee was provided the services by a contract provider. The file does not show that the plan provided notice that the services would not be covered. The EOC alone is not adequate notice of non-coverage. Under Medicare rules, this means the services is considered approved by the plan. Therefore, we decided that the Plan has to pay for the services provided to the enrollee by the contracted provider on September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for debridement, subcutaneous tissue services providedon August 27, 2019.You asked the Plan to pay forthe debridement services. 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 servicesat 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 fordebridement, subcutaneous tissue services provided on August 27, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on September 25, 2019.
You asked the Plan to pay for foot orthotics. You say that the shoe inserts will hopefully prevent the more
costly and invasive surgery to correct your foot condition. The Plan denied your request. The Plan says this
item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on September
25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on July 19, 2019.
You asked the Plan to pay for the pump assembly and operation. You say that the perfusionist is always required by the hospital to be in the operating room and is separate from the surgeon and hospital. The Plan denied your request. The Plan says payment for this service would be included in the part-A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, the member received these services while inpatient. The payment for this service is included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on July 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient infusion services provided from August 17, 2019 to August 31, 2019.You asked the Plan to waive the copayment for these services. You say that Medicare has not made any payment for these services.The Plan denied your request. The Plan says that cost sharing is a contractual obligation under the plan and cannot be waived.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Yourcontract with the Plan clearly says that you must pay a $295 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital. You have been asked to pay a $2,762.85 copayment for these services. These services fall within the Medicare-covered surgery or other services provided to you at an outpatient hospital benefit category. This means that you have been asked to pay less than 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 forthe outpatient infusion services provided from August 17, 2019 to August 31, 2019.