Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve denosumab (Prolia).
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee does not have a history of osteoporotic fracture, or has tried and failed Zoledronic acid.
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. Our physician reviewer found that the enrollee has age-related osteoporosis without current pathological fracture. The Plan requires a trial of Zoledronic acid, or a history of osteoporotic fracture before they will approve the requested drug. The case file does not contain documentation of a trial of Zoledronic acid or a history of osteoporotic fracture. The documentation does not support that Zoledronic acid would likely be less effective or would likely have adverse effects for the enrollee in this case.
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 have not been met. Therefore, we decided that the Plan does not have to pre-approve denosumab (Prolia).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the co-payments for the strapping of the foot and the ultrasound therapy provided December 22, 2020.

You asked the Plan to reduce the co-payments for the strapping of the foot and the ultrasound therapy. You say that the Plan told your doctor that you would only pay 20% for the services. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 co-payment for each Medicare-covered podiatry visit and a $30 co-payment for each Medicare-covered physical therapy and/or speech and language pathology visit. For each service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $35 for a podiatry visit and $30 co-payment for the physical therapy.

You have been asked to pay a $31.63 co-payment for the strapping of the foot and a $16.03 co-payment for the ultrasound therapy. The strapping of the foot falls within the "Podiatry services" benefit category. The ultrasound therapy falls within the "Outpatient rehabilitation services" benefit category. The record shows that strapping the foot is considered a surgical procedure that was done by a podiatrist. The record shows the ultrasound therapy is considered a physical therapy treatment.

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 reduce the co-payments for the strapping of the foot and ultrasound therapy provided on December 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor.
You asked the Plan to pre-approve a Dexcom continuous glucose monitor. You say that this item is medically necessary. The Plan denied your request. The Plan says this is not considered medically necessary as the reasonable useful lifetime of the current continuous glucose monitor.
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 you have a Freestyle Libre continuous glucose monitor. This Freestyle Libre continuous glucose monitor serves the same purpose as a Dexcom continuous glucose monitor. Therefore, we decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex surgery.

You asked the Plan to pre-approve Vertiflex surgery. You say that this request is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex is not medically necessary as this is considered not the standard of care.

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 Vertiflex surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy before this can be approved for coverage. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex surgery.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scans provided July 23, 2020 to
December 14, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that you claim processed with an
incorrect copay and you would like to appeal. The Plan denied your request. The Plan says this claim was
processed, and the correct copayment was applied per the Evidence of Coverage.
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 $200
copay for Medicare covered diagnostic radiology services.
You have been asked to pay $505 for the CT scans. The CT scan falls within the Outpatient diagnostic tests and
therapeutic services and supplies 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 CT scans provided July 23, 2020 to December 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on February 5, 2021 under the Pick Your Perks Reimbursement Program.

You asked the Plan to pay for the physical therapy under the Pick Your Perks Reimbursement Program. The Plan denied your request. The Plan says physical therapy is not a covered benefit under the Pick Your Perks Reimbursement Program.

The Plan contract covers a supplemental benefit under the Pick Your Perks Reimbursement Program.

We looked at the file and the Plan's rules. The file shows that the physical therapy is not covered under the Plan's supplemental benefit. Therefore, we decided that the Plan does not have to pay for physical therapy provided on February 5, 2021 under the Pick Your Perks Reimbursement Program.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on February 10, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you are disputing this charge since it was a virtual visit. You say you had two visit last year and were under no obligation to pay. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
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 each office visit or telehealth visit to a specialist. You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan says cost share has been waived for certain telehealth services only when treatment is Covid-19 related. 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 specialist office visit provided on February 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex surgery.

You asked the Plan to pre-approve Vertiflex surgery. You say that this service is medically necessary. The Plan
denied your request. The Plan says Vertiflex surgery is experimental/investigational.

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 Vertiflex surgery. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and
efficacy of the device before this device can be approved.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Vertiflex surgery have not been met. Therefore, we decided that the Plan does
not have to pre-approve Vertiflex surgery.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana (arformoterol).

You asked the Plan to pre-approve Brovana. You say that the start of Brovana nebulizer solution is to prevent additional exacerbations of the enrollee's chronic obstructive pulmonary disease (COPD). The Plan denied your request. The Plan says there is no indication that the preferred drug would be less effective or cause adverse effects for the enrollee.

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 Brovana. Our reviewer says that Brovana is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has tried and failed the required drug. The reviewer found that there is no indication that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the requested drug, Brovana, 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 Brovana have not been met. Therefore, we decided that the Plan does not have to pre-approve Brovana (arformoterol).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Hyalgan injection (J7321).

You asked the Plan to pre-approve the injection. You say that the enrollee has tried arthritis medication and glucosamine. You say that the enrollee has also tried an assisted device such as compression sleeves and home exercise will little to no help. The Plan denied your request. The Plan says that the requesting provider is from a chiropractic office. The Plan says that the only care billable under the care of a chiropractor is that of manual manipulation.

The Plan must follow Medicare rules. Medicare rules say that an NP services are only covered when they are performed in collaboration with one or more physicians (MD/DO). 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Hyalgan injection (J7321).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for the requested CGM.

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, does not use insulin with at least three daily injections, and does not 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 a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana.
You asked the Plan to pre-approve Brovana. You say that this is medically necessary. The Plan denied your
request. The Plan says this cannot be used with the enrollee's other medication.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Brovana. Our reviewer says that the
requested use of Brovana is not supported. Our physician reviewer found the addition of Brovana, which is a
long-acting beta agonist (LABA) administered via nebulizer, is not medically necessary and is contraindicated,
because the patient is already on a LABA. The records indicate the Stiolto is being continued, and this would
represent double dosing with LABA.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Brovana have not been met. Therefore, we decided that the Plan does not have
to pre-approve Brovana.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the strapping of the ankle/foot and the ultrasound therapy provided on December 18, 2020 and December 28, 2020.
You asked the Plan to reduce the copayments for the strapping of the ankle/foot and the ultrasound therapy. You say that the Plan told your doctor that you would only pay 20% for the services. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
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 $35 copayment for each Medicare-covered podiatry visit and a $30 copayment for each Medicare-covered physical therapy and/or speech and language pathology visit. For each service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $35 for a podiatry visit and $30 copayment for the physical therapy.
You have been asked to pay a $31.63 copayment for the strapping of the foot and a $16.03 copayment for the ultrasound therapy on each date of service. The strapping of the foot falls within the "Podiatry services" benefit category. The ultrasound therapy falls within the "Outpatient rehabilitation services" benefit category. The record shows that strapping the foot is considered a surgical procedure that was done by a podiatrist. The record shows the ultrasound therapy is considered a physical therapy treatment.
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 reduce the copayments for the strapping of the ankle/foot and the ultrasound therapy provided on December 18, 2020 and December 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a follow up visit with an out-of-network provider.

You asked the Plan to pay for a follow up visit. You say that you had a one-year checkup scheduled prior to
signing with the Plan. You say that it is necessary to complete this last review with the doctor who did the
surgery and can switch to a network provider in the future. 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 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 a follow up visit with 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 (L0650) and miscellaneous equipment (A9900) provided on September 1, 2020.

You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this provider is not a Medicare certified DME supplier.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled as a Medicare DME supplier. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) and miscellaneous equipment (A9900) provided on September 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on October 22, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on October 22, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that this is the only sustainable solution. The Plan denied your request. The Plan says your needs can be met at the current facility.
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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found you appear to be improving and more stable, requiring additional short-term acute care services which can be safely administered at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current facility. 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care facility. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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 admission to a long-term acute care hospital (LTACH) for the enrollee.