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

We decided that the Plan has to pre-approve Orencia.
You asked the Plan to pre-approve Orencia. You say that the requested Orencia is medically necessary. The Plan denied your request. The Plan says that the enrollee must try and fail Remicade, Inflectra, or Simponi Aria first.
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 Orencia. Our reviewer says that the requested Orencia is medically necessary. Our physician reviewer found the enrollee is with diffuse joint pain related to rheumatoid arthritis. She has failed multiple treatments, Orencia injections have been requested. The health plan denied coverage for the Orencia as the plan requires a trial of drug(s) Remicade, Inflectra, or Simponi Aria before they will approve the requested drug. Based on the medical records provided the enrollee has not tried and failed the required drug(s). The prescriber has stated that the enrollee is at high risk for infections as manifested by recurrent prior respiratory infections and that Orencia is preferred over the step therapy alternatives because of this. Based on the medical records provided and citation in Micromedex/Drugdex there is documentation that the risk of infectious complications is higher with Remicade or Inflectra compared to Orencia (Desai RJ, Thaler KJ, Mahlknecht P, Gartlehner G, McDonagh MS, Mesgarpour B, Mazinanian A, Glechner A, Gopalakrishnan C, Hansen RA. Comparative Risk of Harm Associated With the Use of Targeted Immunomodulators: A Systematic Review. Arthritis Care Res (Hoboken). 2016 Aug;68(8):1078-88. doi: 10.1002/acr.22815. PMID: 26663412). There is no direct comparison with Simponi Aria in the above noted review article, but Simponi Aria carries the same black box warning with regard to infectious complications as does Remicade and Inflectra. Orencia does not carry any such black box warning.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orencia have been met. Therefore, we decided that the Plan has to pre-approve Orencia.
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 waive the copayment for the chemodenervation procedure you had at an outpatient hospital facility on October 5, 2020.
You asked the Plan to waive the copayment for the chemodenervation procedure. You say that you have to have this procedure often and you cannot afford the copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $200 copayment for outpatient services not provided in an ambulatory surgical center. You have been asked to pay a $200 copayment for the chemodenervation procedure. The chemodenervation procedure falls within the outpatient services not provided in an ambulatory surgical center 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 chemodenervation procedure you had at an outpatient hospital facility on October 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the seed implantation surgery provided on October 9, 2020.
You asked the Plan to waive the copayment for the seed implantation surgery. You say that you were told this procedure was a part of your surgery on October 12, 2020. You say you were never told you would have two outpatient surgery charges. 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 $450 copayment for outpatient hospital facility. You have been asked to pay a $450 copayment for the seed implantation surgery. The seed implantation surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 seed implantation surgery provided on October 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on March 22, 2020.
You asked the Plan to pay for the testing services. You say that the testing was ordered to determine if there was a more effective therapy to treat the enrollee's advanced cancer. The Plan denied your request. The Plan says the testing does not fall within the standard of care for the treatment of colon cancer.
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing is only covered under certain medical indications.
We looked at the file and the rules. The medical records show that the enrollee is being treated for colon cancer. Guardant360 testing is only covered for those with non-small cell lung cancer. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on March 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the extractions (D7140 x 2) provided on November 9, 2020.
You asked the Plan to pay the in network rate for the dental services. You say that you were advised by a plan representative that the provider in this case was in network. You say that now you are being billed for the services that you received from this provider. You also say that you expect the plan to pay for these services as the error is on the plan and not you. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that there is no record of a phone call to the Plan prior to the date of service to verify benefits and provider eligibility.
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, dental items or services that you receive out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in network rate for the extractions (D7140 x 2) provided on November 9, 2020.
Your complaint about being misled by a plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis and ankle-foot orthosis with heel stabilizer rendered on August 26, 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 there is no valid physician order. The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary. We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 pay for the lumbar-sacral orthosis and ankle-foot orthosis with heel stabilizer rendered on August 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital outpatient clinic visits provided on July 9, 2020 and July 16, 2020.
You asked the Plan to pay for the hospital outpatient clinic visits. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for hospital outpatient clinic visits provided on July 9, 2020 and July 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on July 12, 2020.
You asked the Plan to pay for the ambulance services. You say that the enrollee was treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 12, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on July 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device is 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 a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is diagnosed with moderate central canal narrowing at L4-5 & neuroforaminal stenosis at L5-S1, unable to tolerate EMG, findings suggestive of radiculitis & lumbar stenosis, has exhausted all conservative treatment. The Vertiflex device is experimental in this case. More research is needed to show safety and efficacy of the device. The Vertiflex device is not medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for CPAP supplies provided on December 7, 2020.
You asked the Plan to pay for the CPAP supplies. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 CPAP supplies. 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 CPAP supplies provided on December 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee. You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.The Plan denied your request. The Plan says that all services that would be provided in the LTACH are being provided in the current acute care setting which is already approved.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. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the deluxe eyeglass frames (V2025) provided on November 28, 2020.
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the eyeglass frames are not payable as they were purchased from an out-of-network provider.
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. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of this item have not been met. Specifically, the eyeglass frames were purchased from an out of network provider. The Plan contract states that you must use an in-network provider for routine vision services and eyewear. Services rendered by an out-of-network provider are not covered. Therefore, we decided that the Plan does not have to issue reimbursement for the deluxe eyeglass frames (V2025) provided on November 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an annual wellness visit (G0438) provided on September 23, 2020. You asked the Plan to pay for an annual wellness visit. You say that you were not aware the office visit in January counted as your annual wellness visit. The Plan denied your request. The Plan says this exceeds the frequency limitation on this service. The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for an annual wellness visit (G0438) provided on September 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that the enrollee is non-weight bearing. The Plan denied your request. The Plan says there are no daily skilled nursing or therapy needs.
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 services. Our physician reviewer found that the enrollee suffered a fracture of his proximal right tibia. The enrollee is under non-weight-bearing restrictions. There are no skilled nursing services identified. The enrollee would be expected to benefit from skilled therapy services, but the documentation does not support the need for skilled therapy on a daily basis in an inpatient setting. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric hospital care provided to the enrollee from September 30, 2020 to October 6, 2020.
You asked the Plan to pay for the inpatient psychiatric hospital care. You say that these services were medically necessary. The Plan denied your request. The Plan says that the enrollee has exhausted this benefit.
The Plan must follow Medicare rules. The rules say that there is a lifetime maximum of 190 days on inpatient psychiatric hospital services available to any beneficiary and once an individual receives benefits for 190 days of care in a psychiatric hospital, no further benefits of that type are available to that individual. The file shows that the enrollee has received 190 days of inpatient psychiatric hospital services. Although the enrollee may still have needed inpatient psychiatric hospital services, the Plan is not required to pay for more than 190 days of inpatient psychiatric hospital services. Therefore, we decided that the Plan does not have to pay for the inpatient psychiatric hospital care provided to the enrollee from September 30, 2020 to October 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on November 15, 2019 to December 27, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that most in-network providers cannot perform such complex detailed drug testing services. The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the lab services provided on November 15, 2019 to December 27, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care.

You asked the Plan to pay for the acute inpatient hospital care. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the inpatient hospital care provided was not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the emergency room (ER) with a history of five days of chest pain and shortness of breath. She stated that the symptoms began after she started a new medication prescribed by her mental health provider. In the ER her vital signs were stable and her physical exam was unremarkable. Laboratory results revealed a blood glucose of 369, normal troponin, and an abnormal urinalysis. The electrocardiogram was without any acute changes. She was evaluated by Cardiology. She was admitted and she was considered stable; troponins were negative and she was discharged home with outpatient follow-up.

The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. The enrollee could have been treated at a different level of care such as observation.

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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care.