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 June 3, 2019 to August 22, 2019. You asked the Plan to pay forthe glucose monitor (E2100), 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 include the 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 Ticketdoes 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 June 3, 2019 to August 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the "provider" circulating target selector tumor assay rendered to "the beneficiary" by "the provider" on January 10, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the testing is not covered.The Plan must follow Medicare rules. The rules say that CTC testing for all malignant diagnoses will be denied as not reasonable and necessary.The services at issue are CTC testing. These services are denied by Medicare as not medically necessary.Therefore, we decided that the Plan does not have to pay for the "provider" circulating target selector tumor assay rendered to "the beneficiary" by "the provider" on January 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveFerumoxytol injectionsYou asked the Plan to pre-approveFerumoxytol. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is no compelling evidence that the enrollee has iron deficiency anemia and there does not appear to be an issue with swallowing medications, gastrointestinal intolerance, or poor oral iron absorption.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Ferumoxytol. Our reviewer says that the enrollee does not meet the Medicare criteria for use of Ferumoxytol. Our physician reviewer found this enrollee does not have indices indicative of iron deficiency. The enrollee completed chemotherapy and radiation and iron studies provided are not consistent with iron deficiency anemia. In addition, Ferumoxytol is non-formulary for Medicare. Therefore, this service is not medically reasonable or necessary for the enrollee's condition.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ferumoxytol have not been met.Therefore, we decided that the Plan does not have to pre-approveFerumoxytol injections
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea myoelectric orthosis for the enrollee.You asked the Plan to pre-approvethese services. You say thatthe enrollee would benefit from this device.The Plan denied your request. The Plan says that this is considered experimental, investigational and unproven.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 a myoelectric orthosis is not medically reasonable and necessary for the enrollee in this case. Myoelectric prostheses have been used for a particular subset of patients since the 1970's but the published, peer-reviewed, scientific literature is not sufficient and therefore this device is investigational for this patient's condition of hemiplegia from a CVA. The prospective clinical studies lack data measuring objective outcomes, improved performance and specific patient selection criteria. Further well-designed randomized, controlled clinical trials with adequate follow-up are needed to determine the overall benefit of these devices. Furthermore, the requested L8702 is not being furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition of hemiplegia from CVA or to improve the function of a malformed body member from hemiplegia from a CVA. Our physician reviewer found that the enrollee's condition does not meet criteria for these 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea myoelectric orthosis for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not havetopay foran office visit provided on August 15, 2019.You asked the Planto pay forthe visit. You say that this should be paid for.The Plandenied your request. The PlansaysMedicare says non-urgent services should be from network providers who are contracted with the healthplan and listed in the Provider Directory.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 rendering 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 Plandoes not haveto pay foran office visit provided on August 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on July 15, 2019.You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an office visit provided on July 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveBotox for the enrollee.You asked the Plan to pre-approveBotox. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that Medicare does not consider gastroparesis as a medically accepted indication for Botox.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Botox. Our reviewer says that Botox is not medically reasonable and necessary for the enrollee in this case. Though trials evaluating the effect of intrapyloric botulinum toxin injection on gastroparesis have been reported, there is no agreement whether botulinum toxin can effectively relieve the symptoms and improve the results of gastric emptying study in patients with gastroparesis. Available records describe symptoms but do not provide documentation of gastroparesis by gastric emptying scan or other methods. Available records do not support the medical necessity, per provided coverage criteria, of ongoing intrapyloric botox injections. Our physician reviewer found that the enrollee's condition does not meet criteria for approval of Botox.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met.Therefore, we decided that the Plan does not have to pre-approveBotox for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fordeep sedation/general anesthesia first 15 minutes (D9223) deep sedation/general anesthesia each subsequent 15 minutes (D9222) provided July 1, 2019.You asked the Plan to pay forgeneral anesthesia. You say that you request review for reimbursement on the required surgery because you believe the enrollee has benefits that cover at least some of the surgical costs.The Plan denied your request. The Plan says this service 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. The health plan contract says any service not listed under the Description of Benefits is not covered.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 topay fordeep sedation/general anesthesia first 15 minutes (D9223) deep sedation/general anesthesia each subsequent 15 minutes (D9222) provided July 1, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe laboratory services and inpatient stay provided on February 14, 2019 and February 28, 2019 through March 2, 2019,You asked the Plan to waive the copayments forthe laboratory services and inpatient stay. You say that you did not understand you had a copayment per day for the first four days. You say that you feel that you do not owethe copayments.The Plan denied your request. The Plan says the copayments 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 $10 copayment for Medicare-covered lab services and a $395 copayment each day for days 1 to 4 for Medicare-covered hospital care. You have been asked to pay $4.37, which is less than the standard $10 copayment for the laboratory services. You have also been asked to pay a $790 copayment for the inpatient stay. ($395/day x 2 days = $790). The total amount you owe is $794.37 ($4.37 + $790 = $794.37). The laboratory services fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The inpatient stay falls within the "Inpatient Hospital Care" 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 forthe laboratory services and inpatient stay provided on February 14, 2019 and February 28, 2019 through March 2, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services. You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee's ongoing care needs include oxygen supplementation with BiPAP support as needed, surveillance laboratory studies, scheduled hemodialysis, wound care, therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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-approvelong term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran outpatient surgery provided by "the hospital" on August 14, 2019.You asked the Plan to waive the copayment foran outpatient surgery. You say that this second surgery was a result from your first surgery. You say that you shouldn't have to pay for a second surgery.The Plan denied your request. The Plan says the correct copayment has been applied.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 $300 copayment for outpatient surgery/in-network. You have been asked to pay a $300 copayment for an outpatient surgery. There is a $300 copayment for each surgery that is performed; therefore, the correct copayment has been applied. An outpatient surgery falls within the outpatient surgery/in-network 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 foran outpatient surgery provided by "the hospital" on August 14, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the admission 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 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the SNF with dementia. She received oral medications and had stable vital signs. She received physical and occupational therapy and, upon evaluation, needed supervision to contact guard assist with functional mobility, including gait to 120 feet with a rolling walker. She needed set up assistance with activities of daily living. She has no skilled nursing needs. She has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF level of 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forintravenous moderate (conscious) sedation/analgesia, first 15 minutes (D9239) provided on July 11, 2019.You asked the Plan to pay forthe IV sedation. You say that the records provided should support the necessity of the services in dispute.The Plan denied your request. The Plan says this service 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. The health plan contract says any services not listed are not covered.Though the Plan offers adental 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 pay forintravenous moderate (conscious) sedation/analgesia, first 15 minutes (D9239) provided on July 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveJuvederm for "the beneficiary".You asked the Plan to pre-approveJuvederm. You say that the Juvederm injection is being used to unfreeze the enrollee's face due to Parkinson's.The Plan denied your request. The Plan says Juvederm to treat Parkinson's disease is not a covered use.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Juvederm. Our physician reviewer found that Juvederm injection is being used to treat drooling related to Parkinson's Disease. The requested use of Juvederm is not FDA-approved for the enrollee's diagnosis. There is no listing of drooling related to Parkinson's Disease as an indication, recommendation or support for use of Juvederm in any of the major drug compendia. Therefore,the requested service is not considered 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 Juvederm have not been met. Therefore, we decided that the Plan does not have to pre-approveJuvederm for "the beneficiary".
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60mg/ml injections.
You asked the Plan to pre-approve Prolia. You say that the Prolia is medically necessary. The Plan denied your request. The Plan says plan rules require a trial of plan preferred drugs before Prolia can be considered.
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 coverage criteria has not been met. Our physician reviewer found the enrollee has not had a documented trial of the plan preferred drug, Zoledronic Acid. The record does not show that Zoledronic acid would be unsafe or ineffective for this enrollee. 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 not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia 60mg/ml injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crowns for teeth # 3 and 4.
You asked the Plan to pre-approve the dental services. You say that you may lose your teeth if the crowns are not approved. The Plan denied your request. The Plan says the crowns for teeth # 3 and 4 are not listed as covered teeth.
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 crowns are listed as a covered services, they are only covered for certain teeth. Teeth # 3 and 4 are not listed as covered teeth for crowns. Therefore, we decided that the Plan does not have to pre-approve the crowns for teeth # 3 and 4.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forBLS emergency ambulance service (A0429) and ground mileage (A0425) provided by "the provider". July 23, 2019.You asked the Plan to pay forthe ambulance services. You say that the enrollee is at a skilled nursing facility and had critical low sodium.The Plan denied your request. The Plan says the criteria for approval of ambulance services have not been met.Medicare pays for ambulance services only when an emergency exists or whenother means of transport would endanger the patient's health. The Plan follows the same rules. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the ambulance services. Our reviewer says that transportation via ambulance to the hospital was not medically necessary. Our physician reviewer found the enrollee was not bedbound, as evidenced by her ability to sit in a wheelchair. The enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport. While medical evaluation may have been reasonable, transportation could have been provided by other means without endangering the enrollee's condition.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 ambulance services have not been met.Therefore, we decided thatthe Plan does not have to pay forBLS emergency ambulance service (A0429) and ground mileage (A0425) provided by "the provider" July 23, 2019.