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

We decided that the Plan does not haveto pre-approve a hot tub (E1399).You asked the Plan to pre-approve the hot tub. You say that the member is at a high risk for further decline, injury and decline in quality of life without the hot tub. The Plan denied your request. The Plan says a hot tub is not primarily and customarily used to treat a medical purpose and is considered generally useful to a person in the absence of illness or injury.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a hot tub (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the audiology services. You say that this provider is in-network and you are covered for hearing aids. The Plan denied your request. The Plan says there are in-network audiologists available within 25 miles.
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 medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) and removal of impacted ear wax (69210) provided on October 22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit and removal of ear wax. You say that you went to Oregon and were diagnosed with cancer and had emergency surgery to remove the cancer. You also had your ears cleaned. You received a hearing test which resulted in needing a hearing aid but will get that in Mesa. You want to appeal these claims as you weren't home to receive these services. The Plan denied your request. The Plan says the claim is denied for an out-of-network provider which was non-emergent or urgent.
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 has network providers available who can provide 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 an office visit (99213) and removal of impacted ear wax (69210) provided on October 22, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided by on September 17, 2019.
You asked the Plan to waive the copayment for urgent care services. You say that you walked into urgent care for ear pain. You thought you were being seen by a doctor and later found out you were seen by a physician's assistant. You were told there was no sinus infection and received a prescription which you felt was too dangerous and didn't take it. You do not understand why the physician assistant gets a specialist copayment when you were seen for only 5 minutes. The Plan denied your request. The Plan says urgent care services have a $30 copayment per visit.
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 $30 copayment for urgently needed services. You have been asked to pay a $30 copayment for urgent care services. This service falls within the urgently needed services 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 urgently needed services provided by on September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services renderedon May 30, 2019.
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 procedure codes 22630 and 22632 are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 22630 is arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar. The definition of code 22632 is arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace (List separately in addition to code for primary procedure). We find that CPT codes 22630 and 22632 are not supported in the medical record. Specifically, the records do not contain documentation of a single lumbar interspace arthrodesis using a posterior interbody technique to support code 22630 or 22632. 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 surgical services rendered on May 30, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee from May 29, 2019 to October 8, 2019.You asked the Plan to pay forhome health services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services were not billed with a valid treatment authorization code.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, a valid treatment authorization code was not submitted with the claim. Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from May 29, 2019 to October 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide a tier exception for Monovisc 88mg/4ml syringe.
You asked the Plan to provide a tier exception for Monovisc. You say that the Monovisc should be covered
under Part D because the enrollee cannot pay the Part B coinsurance. The Plan denied your request. The Plan
says Tier exceptions are not available for Part B drugs. Monovisc injections are covered under Part B.
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 a 20% coinsurance for Part B Drugs.
The enrollee has been asked to pay a 20% coinsurance for Monovisc. Monovisc falls within the Part B Drugs
benefit category. Monovisc is not eligible for Part D coverage. 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 provide
a tier exception for Monovisc 88mg/4ml syringe.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to a tertiary-level retina specialist.You asked the Plan to pre-approvethese services. Yousay that the services are medically necessary.The Plan denied your request. The Plan says the tertiary level of care 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 these services. Our reviewer says that the tertiary level of care is not medically necessary. Our physician reviewer found the submitted records show that you have macular degeneration and were previously treated in 2015. The records show that your condition can be adequately treated by the in-network, non-tertiary retina specialists. The Plan has made good effort to ensure there are appropriate providers available to provide your treatment. The tertiary level of care is not reasonable or 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea referral to a tertiary-level retina specialist.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe electrophysiologic evaluation provided from August 15, 2019 through August 16, 2019.You asked the Plan to waive the coinsurance forthe electrophysiologic evaluation. You say that the Plan should pay more. You say that you want to know why you owe so much.The Plan denied your request. The Plan says the coinsurance applied 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 40% coinsurance for Medicare-covered surgery or other services provided to you at an out-of-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.You have been asked to pay $4,220.85, which is less than the standard 40% coinsurance for the electrophysiologic evaluation. The electrophysiologic evaluation falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The records show the provider is out-of-network. This meansthat 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 forthe electrophysiologic evaluation provided from August 15, 2019 through August 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana at a lower cost for the enrollee.You asked the Plan to pre-approvethe tier exception. The Plan denied your request. The Plan says a tier exception cannot be granted for Part B medications.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 a 20% coinsurance for Medicare Part B prescription drugs. The enrollee has been asked to pay a 20% coinsurance for the requested drug. The drug falls within the Medicare Part B prescription drugs benefit category. 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 pre-approveBrovana at a lower cost for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from IRF care.The Plan denied your request. The Plan says the criteria for this level of care are not met.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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is a an 81-year-old woman who presented with a 2 day history of a fall on 2/6/20, which resulted in a fracture of the neck of the left femur. A hemiarthroplasty of the left hip was performed on 2/7/20, and the enrollee tolerated it well. On 2/18/20, the enrollee ambulated 20 feet with front wheeled walker and Min assistance. She had low activity tolerance and required encouragement secondary to fatigue.The patient is generally medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient PMR physician three times per week or acute rehab nursing care. While the enrollee may benefit from continuing PT and OT, the evidence does not suggest that the enrollee would be able to participate in an intensive therapy program with therapy 3 hours per day. The documentation does not support a need for frequent physician oversight and an interdisciplinary approach to rehabilitation care.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 not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forvitamin B-12 (82607), and an assay of Ferritin (82728) provided on June 24, 2019 by an out of network (OON) provider.You asked the Plan to pay forvitamin B-12 and an assay of Ferritin. You say that your services were medically necessary to treat your medical condition.The Plan denied your request. The Plan says you must receive your care from a network provider. In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be covered. The plan covers emergency care or urgently needed services that you get from an out-of-network provider. If you need medical care that Medicare requires our plan to cover, and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. The medical care will be coordinated for you with an out-of-network provider. Prior authorization from our plan must be obtained priorto obtaining services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Planhas 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 has network providers available who can provide 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 forvitamin B-12 (82607), and an assay of Ferritin (82728) provided on June 24, 2019 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 you are appealing with medical records.The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.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 as LTACHs and acute care hospitals are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current acute care hospital until such time as no acute services are required then be transferred/discharged to a lower level of care for any ongoing long-term care 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 the LTACH services have not been met.Therefore, we decided that the Plan does nothave to pre-approvelong term acute care hospital (LTACH) services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vitamin D2.You asked the Plan to pre-approveVitamin D2. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered 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-approveVitamin D2.Benefits for Vitamin D2may be available under Medicare Part D.Contactthe 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 pre-approve a Synvisc-One injection for the enrollee.
You asked the Plan to pre-approve a Synvisc-One injection. You say that this is medically necessary. The Plan denied your request. The Plan says that one of the above preferred alternatives can be tried.
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 a Synvisc-One injection. Our reviewer says that Synvisc-One is not medically reasonable and necessary for the enrollee in this case. The enrollee has not trialed viscosupplementation treatments such as Orthovisc and Monovisc. The documentation does not outline contraindications or reasons these medications were not considered. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Synvisc-One. 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 Synvisc-One injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Synvisc-One injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power operated vehicle (scooter).You asked the Plan to pre-approvepower operated vehicle. You say that the enrollee has multiple medical problems and a motorized scooter would be appropriate for use.The Plan denied your request.The Plan says the denial of authorization for this item is correct, because the enrollee does not meet the Medicare criteria for this power operated vehicle.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 power operated vehicle. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested power operated vehicle. Our physician reviewer found the enrollee does not have a personal mobility deficit that impairs participation in mobility-related activities of daily living. The enrollee's mobility deficits can be helped by the use of a walker, cane, or manual wheelchair. If any power operated vehicle or power wheelchair is only for use outside of the home, it will be denied as non-covered.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power operated vehicle have not been met.Therefore, we decided that the Plan does not have to pre-approvea power operated vehicle (scooter).