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

We decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided by "the provider" from July 31, 2019 to October 19, 2019.You asked the Plan to pay forthe glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not includethe carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided by "the provider" from July 31, 2019 to October 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveincomplete endodontic therapy.You asked the Planto pre-approvethe therapy. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plandoes not haveto pre-approveincomplete endodontic therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental deep sedation services.You asked the Plan to pre-approve these services. You say that you have dental phobia and need the sedation services.The Plan denied your request. The Plan says the services are not covered.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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvedental deep sedation services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea referral for the enrollee to receive Gamunex. You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansaysthis infusion/injection is required to be provided by "in Network." Medicare rules saythat 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 pre-approved care."out of network provider"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 Plandoes not haveto pre-approvea referral for the enrollee to receive Gamunex.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to reduce the cost for the porcelain or ceramic crown provided on July 17, 2019.
You asked the Plan to reduce the cost for the crown. You say that the allowed amount was used to calculate the
Plan's payment but the billed amount was used to calculate your obligation. You say that your obligation
should only be $350. The Plan denied your request. The Plan says that your cost was calculated correctly.
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.
The Plan says you must pay $850 for the porcelain or ceramic crown. Based on the Plan contract, however, you
cannot be asked to pay more than $350. The Plan contract says that balance billing is not allowed. Therefore,
we decided that the Plan has to reduce the cost for the porcelain or ceramic crown provided on July 17, 2019
from $850 to $350.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hymovis.You asked the Plan to pre-approve Hymovis. You say that the records provided supports the need for the requested drug.The Plan denied your request. The Plan says the enrollee has not met the step therapy requirements.Medicare covers Part B medications when they are reasonable and necessary butallows 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 Hymovis. Our reviewer says that the criteria for coverage of the requested drug have not been met. Our physician reviewer found there is no documentation of prior use of the required Monovisc and Orthovisc alternatives. There is no documentation of any adverse reaction to a trial of these medications. There is no specific clinical rationale for the requested medication and there is no documentation supporting that the Plan's required drugs would be less effective in the enrollee's treatment.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hymovis have not been met.Therefore, we decided that the Plan does not have to pre-approveHymovis
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve seat and back cushions.You asked the Plan to pre-approve seat and back cushions. You say that the Plan should pay for cushions so you are not continually in pain while sitting.The Plan denied your request. The Plan says if you do not have a covered wheelchair then the cushions will be denied as not reasonable and necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medicallynecessary are not covered. Medicare rules say a positioning cushion/pillow/wedge, any shape or size,(E0190) is statutorily excluded by Medicare as not reasonable and necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of seat and back cushions have not been met.Therefore, we decided that the Plan does not have to pre-approveseat and back cushions.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on August 26, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.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 services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on August 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tiering exception for Levalbuterol for the enrollee.You asked the Plan to pre-approve a tier exception. The Plan denied your request. The Plan says that tiering exceptions are not available for Part B drugs.The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D drugs. The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for coverage of a tier exception have not been met.Therefore, we decided that the Plan does not have to pre-approvea tiering exception for Levalbuterol for the enrollee
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network
provider on November 1, 2018.
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 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 services. Therefore, we decided that
the Plan does not have to pay for the medical services provided to you by an out-of-network provider on
November 1, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care can be received in another setting.
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's medical conditions appear stable. There are no complex wound care needs. She does not require medical oversight of her condition at an acute hospital level of care. The enrollee is limited by debility and the severity of her comorbid medical and neurological conditions. She is not participating in the speech therapy treatments being offered despite encouragement. She would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. The enrollee's care can be appropriately provided at an SNF level. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.You asked the Plan to pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plan says there are in-network facilities available that can perform the scans.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 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. 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-approvea referral to an out-of-network provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approveSNF services. You say that the enrollee requires rehab until her arm is healed so she can go back to her memory facility.The Plan denied your request. The Plan says that the enrollee cannot participate in therapy due to cognitive deficits which prevent ability to learn concepts for safe execution of functional program.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee
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 the enrollee's medically stable and does not require hospital level care. You say that it is now important to start aggressive ventilator weaning, as well as therapy. You say that the enrollee needs close monitoring The Plan denied your request. The Plan says the enrollee does not meet the requirements for coverage of LTACH care. The Plan says that the enrollee's care can be provided in the current inpatient hospital.

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 the enrollee does not required services at the LTACH which are not available at the acute care hospital where he is currently receiving care. All medically necessary care is being provided in the current acute care setting. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The health plan has approved ongoing care in the current acute care 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 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 computed tomography (CT) scan services.You asked the Plan to pre-approvethe CT scan. You say that this was a recommended CT order for 6-8 wees from the one the enrollee had on November 13, 2019.The Plan denied your request. The Plan says that the information received did not show that the enrollee's clinical condition was worsening. The plan says that the enrollee does not have reduced ability to fight infection. The plan says that the records send do not show that the enrollee had persistent pneumonia on follow-up chest x-ray. The plan say that the enrollee does not have a history of recurrent pneumonia noted.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 CT scan. Our reviewer says that the requested CT scan of the chest is medically reasonable and necessary. Our physician reviewer found the enrollee is a 66-year-old woman who had an abnormal CT of lungs on November 16, 2019 showing a right peripheral opacity. Radiology assessment was that the findings could represent pneumonia, but a 6 week follow up CT was recommended toensure resolution. The enrollee was treated for pneumonia and is asymptomatic.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 CT scan have been met.Therefore, we decided that the Plan has to pre-approvecomputed tomography (CT) scan services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLantus Solostar injector pens.You asked the Plan to pre-approveself-administered drugs. You say that the enrollee has been on this drug since 2013 and it is medically necessary.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.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-approveLantus Solostar injector pens.Benefits for self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEuflexxa.You asked the Plan to pre-approveEuflexxa. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee has not tried and failed Monovisc and Orthovisc as required by step therapy rules.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 Euflexxa. Our reviewer says that criteria for coverage of Euflexxa have not been met. Our physician reviewer found the Plan requires a trial of Monovisc and Orthovisc before they will approve the requested drug. The documentation does not support that the enrollee has tried and failed Monovisc and Orthovisc or that Monovisc and Orthovisc would likely be less effective or would likely have adverse effects for the enrollee in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met.Therefore, we decided that the Plan does not have to pre-approveEuflexxa.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says the enrollee does not have any complex wound care or medical complexity to support the need for an inpatient rehab physician 3 times a week.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 is stable, with no signs of toxicity or sepsis. The enrollee is at minimal assist for functional transfers and activities of daily living. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with 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-approveacute inpatient rehabilitation facility (IRF) admission and services.