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

We decided that the Plan does not have to pre-approve a replacement continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the replacement monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the provided documentation does not indicate that the current monitor is beyond repair.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. 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 replacement monitor. Our reviewer says that the requested replacement monitor is not medically reasonable or necessary. Our physician reviewer found the enrollee already has a CGM. Her provider is requesting a CGM with alarms to notify the enrollee of hypoglycemia. While the documentation shows that the enrollee has had some recent hypoglycemia, the documentation also shows that the enrollee has not been taking her medications correctly. Medication adjustments were made in October 2019. No documentation of how those adjustments affected the enrollee's blood glucose levels has been submitted for review. There is no documentation that the enrollee's current CGM is non-functional. Therefore, the request for a new/different CGM is not shown to be currently medically necessary or reasonable. 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 replacement monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement continuous glucose monitor for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on February 13, 2019 by out of network provider.You asked the Plan to pay forvision care services. You say that you did not have the opportunity to obtain an authorization prior to treatment, and these services were medically necessary.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the enrollee self-directed for service.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 forthe medical services provided on February 13, 2019 by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp for the enrollee.
You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says that they did not receive documentation or medical records supporting the medical necessity for a step therapy exception.
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 Aranesp. Our reviewer says that Aranesp is not medically reasonable and necessary for the enrollee in this case. Criteria for epoetin alfa/darbepoetin alfa therapy is not supported due to low ferritin and low transferrin saturation. The provided medical records do not indicate that the enrollee has tried and failed the Plan's required drug or that it would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found the enrollee's condition does not meet criteria for coverage of Aranesp. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns for teeth #2, 6, 15, and 30.You asked the Plan to pre-approvecrowns for teeth #2, 6, 15, and 30. The Plan denied your request. The Plan says the crowns are 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 crowns for teeth #2, 6, 15, and 30. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that due to the fact that the documentation does not show significant breakdown (>50%) of tooth structure due to caries or fracture, the criteria for coverage for crowns on teeth #2, 6, 15and 30 has not been met.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of crowns for teeth #2, 6, 15, and 30 have not been met.Therefore, we decided that the Plan does not have to pre-approvecrowns for teeth #2, 6, 15, and 30.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the occupational therapy (OT) services provided on July 16, 2019.
You asked the Plan to waive the copayment for these services. You say that the services were within the global period after total elbow replacement and should have no copayment. The Plan denied your request. The Plan says the copayment was 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 a $20 copayment for each visit for Medicare-covered occupational and speech language therapy services.
Review of the file shows that you received OT services on July 16, 2019. These services are not included in the global surgical package. You have been asked to pay a $20 copayment for these services. These services fall within the Medicare-covered occupational and speech language therapy 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 the occupational therapy (OT) services provided on July 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the provider.
You asked the Plan to pre-approve IRF care. You say that the enrollee is unable to walk or speak. The Plan denied your request. The Plan says there is no medical complexity that would require a specialty-trained multidisciplinary rehab team.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee's current level of function is ambulation with minimal assistance using a rolling walker, and standing with minimal assist. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee required the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional physical and occupational therapy, but he does not require this on an intensive rehabilitation facility therapy program level in an IRF. 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 for the enrollee
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the radiology services provided on August 22, 2019.
You asked the Plan to waive the copayment for the radiology services. You say that you feel you should not be responsible for this cost share amount and you would like the plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient radiology services on the date of service at issue in this appeal. The plan states the correct copayment has applied per your contract with the plan.
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 $250 copayment for Medicare-covered diagnostic radiology services (not including x-rays). We looked at the file, the Plan contract and Medicare rules. The file shows you received radiology services on August 22, 2019. You have been asked to pay a $250 copayment for the radiology services. The radiology services fall within the Outpatient diagnostic tests 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 radiology services provided on August 22, 2019.
Your concern regarding being provided the incorrect cost share amount is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of concerns.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to D. Stoute by Thyroid Specialty Laboratory on May 16, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered to D. Stoute by Thyroid Specialty Laboratory on May 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee by the laboratory on August 1, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered to the enrollee by the laboratory on August 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the fabric back brace (A4467)
You asked the Plan to pay for the back brace. You say that are in need of a back brace to aid in walking which is the recommended exercise. The Plan denied your request. The Plan says Medicare only covers rigid or semi-rigid brace.
The Plan must follow Medicare rules. Medicare rules say that Elastic or other fabric support garments with or without stays or panels do not meet the statutory definition of a brace because they are not rigid or semi-rigid devices. We looked at the file and Medicare rules. The back brace prescribed does not have rigid or semi-rigid panels, therefore it is noncovered. Based on this information, we decided that Medicare rules for coverage of the back brace have not been met. Therefore, we decided that the Plan does not have to pay for the fabric back brace (A4467).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ophthalmological medical examination and evaluation provided on
June 3, 2019.
You asked the Plan to waive the copayment for the ophthalmological medical examination and evaluation. The Plan denied your request. The Plan says the claim processed correctly with a $35 copayment.
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 $35 copayment for vision care. You have been asked to pay $35 copayment for the ophthalmological medical examination and evaluation. The ophthalmological medical examination and evaluation falls within the vision care, Medicare-covered exams 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 ophthalmological medical examination and evaluation provided on June 3, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve myocardial perfusion imagingYou asked the Plan to pre-approvethe imaging. The Plan denied your request. The Plan says that the coverage criteria are not met.The Plan follows Medicare rules. Medicare rules say that cardiovascular nuclear medicine is covered for the above indications.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 imaging. Our reviewer says that the requested myocardial perfusion imaging is not medically reasonable and necessary. Our physician reviewer found that the enrollee has multiple risk factors for coronary artery disease (hypertension, hyperlipidemia, strong family history CAD) and also some known aortic vascular disease. He is at intermediate to high risk for significant cardiovascular disease based on his age and these other risk factors. He also describes chest pressure and dyspnea on exertion. As he has symptoms consistent with angina and also is at significantly elevated risk for ischemic cardiovascular disease, nuclear stress testing is both appropriate and medically necessary in this enrollee and meets the LCD criteria.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 imaging have been met.Therefore,we decided that the Plan has to pre-approvemyocardial perfusion imaging
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on June 20, 2019 by the out of network provider.
You asked the Plan to pay for the physician services. You say that you are in the process of gaining credentials. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says that the service was not urgent or emergent.
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 provider in this case is not a network provider with the Plan. The referring provider is not a network provider either. 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 the home visit provided on June 20, 2019 by the out of network provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from May 10, 2019 through May 13, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed 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. 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from May 10, 2019 through May 13, 2019.
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: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from July 10, 2019 through July 12, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed 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. 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from July 10, 2019 through July 12, 2019.
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 Prednisone tab 10mg.
You asked the Plan to pre-approve Prednisone tab 10mg. You say that the requested medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit, therefore self-administered drugs do not meet the criteria for coverage.
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 Prednisone tab 10mg.
Benefits for Prednisone tab 10mg 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit provided on August 9, 2019 by out of network provider.
You asked the Plan to pay for the out-of-network services. You say that the care provided was medically necessary, and consistent with standards of practice. The Plan denied your request. The Plan says there is no network deficiency for the services provided.
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 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 out-of-network services. Therefore, we decided that the Plan does not have to pay for the hospital outpatient clinic visit provided on August 9, 2019 by out of network provider.