Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for office visits provided on April 26, 2021, and April 27, 2021.
You asked the Plan to waive the copayments for office visits. You say that you had to return a second time because the treatment was ineffective and you feel that you should only owe one copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $10 copayment for primary care provider visits and a $35 copayment for specialist visits. You had a specialist visit on April 26, 2021. Therefore, you are responsible to pay the $35 copayment. You had an office visit on April 27, 2021. Therefore, you are responsible to pay the $10 copayment. The total amount you owe is: $45.
You have been asked to pay the total copayment amount of $45 for office visits. Office visits fall within the physician/practitioner services, including doctor's office visits 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 copayments for office visits provided on April 26, 2021, and April 27, 2021.
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. The Plan denied your request. The Plan says you do not have 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 your current level of function is at a minimal assist level for bed mobility, transfers, and ambulation. You need assistance for all activities of daily living for safety. You have no daily skilled nursing needs. At the current level of function, with worsening dementia, you do not require daily skilled therapies 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a tissue exam by a pathologist (88305) provided on April 5,
2021, by an out-of-network (OON) provider.
You asked the Plan to pay for laboratory services. You say that you are requesting reconsideration of the
denied claim. The Plan denied your request. The Plan says services were provided by an out-of-network
provider without 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 records provided for review
also show that the enrollee was referred by a non-participating provider. 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 tissue exam by a pathologist (88305) provided
on April 5, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of bone density cited.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy of the device.
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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies haven't proven that this device is helpful for treatment of the health problem.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the device.

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on April 26, 2021, by an
out-of-network (OON) provider.

You asked the Plan to pay for an office visit. You say that the member has chronic kidney disease, and the
services are medically necessary. The Plan denied your request. The Plan says services were provided by an
out-of-network provider without 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 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. The records provided for review do not show that the services at issue were urgent or
emergent. 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 an office visit (99214) provided on April 26, 2021, by an out-ofnetwork
(OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that Prolia is the best choice for the enrollee. The Plan denied your request. The Plan says that step therapy requirements have not 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. Our reviewer says that the requirements for coverage of Prolia have been met. Our physician reviewer found the Plan requires a trial of an oral bisphosphonate drug and zoledronic acid before they will approve the requested drug. The enrollee has tried Fosamax and Boniva. While the enrollee has not tried and failed zoledronic acid, the documentation in the case file supports that zoledronic acid would be more likely to have adverse effects for the enrollee in this case. The enrollee's endocrinologist writes that zoledronic acid will cause prolonged suppression of the C-terminal cross-linked telopeptide (CTX), which is already at the low end of normal, and may increase the risk of atypical femoral fracture. 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 been met. Therefore, we decided that the Plan has to pre-approve Prolia.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tolvaptan.

You asked the Plan to pre-approve Tolvaptan. The Plan denied your request. The Plan says your medical plan does not cover outpatient prescription drugs.

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 Tolvaptan.

Benefits for Tolvaptan 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided on December
29, 2020.

You asked the Plan to pay for the self-administered drugs. You say that you would like reconsideration because
Medicare said the Plan would take care of this. The Plan denied your request. The Plan says Medicare Part B
does not pay for self-administered drugs.

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 pay for the self-administered drugs
(A9270) provided on December 29, 2020.

Benefits for the self-administered drugs 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance service (A0428, A0425) provided on March 26, 2021.
You asked the Plan to waive the copayment for an ambulance service. You say that the enrollee should not be liable for the cost share because he was transported from one facility to another facility for Covid recovery. The Plan denied your request. The Plan says the copayment the enrollee is being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay $275 copayment per one-way trip for ambulance services. The enrollee's contract with the Plan also says that non-emergency transportation by ambulance is appropriate if it is documented that the member's condition is such that other means of transportation could endanger the person's health and that transportation by ambulance is medically required The enrollee has been asked to pay a $275 copayment for an ambulance service. The EOC confirms $275 is the required copayment for this service. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ambulance service (A0428, A0425) provided on March 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. 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. 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 pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found the documentation does not support that it is reasonable to expect that the enrollee's necessary hospital care will span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture with resin base (D5211).
You asked the Plan to pre-approve the dental service. You say that your partial denture broke in a fall. You also say that you need a new one. The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan also says that the frequency limit has been reached.
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 and partial upper denture with resin base is listed as a covered service, the frequency limit has been reached. The record shows that the Plan paid for a partial upper denture with resin base that you received on August 18, 2020. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture with resin base (D5211).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on April
7, 2021.
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 services provided by an out-of-network provider on April 7,
2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for Freestyle Libre CMG reader/sensor (CPT code K0554) provided to the enrollee on March 18, 2021.
You asked the Plan to pay for the DME. You say that the enrollee's current primary care physician (PCP) ordered the CGM. The Plan denied your request. The Plan says that they have contacted enrollees and found that the provider is cold calling to the enrollee. The Plan states the enrollee receiving devices but not ordering them.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Review of the file shows that the Plan's only argument is the provider cold-calling the enrollee; however, there is a fax from the DME provider to the enrollee's PCP. Therefore, there was clearly appropriate communication between this DME vendor and the enrollee's PCP. The Plans denial is not supported. Therefore, we decided that the Plan has to pay for Freestyle Libre CMG reader/sensor (CPT code K0554) provided to the enrollee on March 18, 2021.
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: 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. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current acute setting.
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 physician reviewer found that in this case, the enrollee was admitted to the acute hospital with exacerbation of congestive heart failure and pneumonia. The enrollee has had a prolonged hospital course. At this time, the enrollee is receiving total parenteral nutrition and oxygen via nasal cannula. She does not require complex wound care. She continues to receive acute care services, and these have not been denied. The medical record does not indicate that she requires services that she is not currently receiving, but that would be available at the LTACH facility. Therefore, the requested services are 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 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT scan of the chest, neck, abdomen and pelvis for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that the clinical documentation submitted does not demonstrate medical necessity.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the enrollee has a proven diagnosis of aggressive diffuse large B cell lymphoma and is on chemotherapy for same. While the most recent CT scans of 2/17/21 showed no evidence of malignant disease, his primary diagnosis is such that recurrence is likely. The most recent PET/CT was negative. The request for a 6-month surveillance CT series in a patient with known malignancy, on chemotherapy and a high probability of tumor recurrence is reasonable and should 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 the scan have been met. Therefore, we decided that the Plan has to pre-approve CT scan of the chest, neck, abdomen and pelvis for the enrollee.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gait belt.

You asked the Plan to pre-approve a gait belt. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered by Medicare.

The Plan must follow Medicare rules. The rules say that safety equipment will always be denied as non-covered. The gait belt is considered safety equipment. Therefore, we decided that the Plan does not have to pre-approve a gait belt.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.

You asked the Plan to pre-approve the SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

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 the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have any documented skilled nursing needs and you do not require daily skilled therapy services 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 the SNF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.