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

We decided that the Plan has to waive the cost share for the office visit, arthrocentesis and shoulder x-ray provided on December 30, 2019.You asked the Plan to waive the cost share for the office visit, arthrocentesis and shoulder x-ray. You say that you were informed you qualified for a plan with no copayments and no gaps in insurance. You say that you were informed you weren't responsible and to disregard the bill.The Plan denied your request. The Plan says that the cost share 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 does not say in clear and accurate terms the Plan deductible amount and when you should expect to pay 20% coinsurance.We looked at your contract with the Plan. We did not see where the contract says the Plan deductible is $185. We also did not see where the contract says when enrollees will be expected to pay 20% coinsurance. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information.Therefore, we decided that the Plan has to waive the cost share for the office visit, arthrocentesis and shoulder x-ray provided on December 30, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual residential service contract for the 2020 year purchased December 16, 2019.You asked the Plan to pay for the annual residential service contract. You say that you were denied last year for the same service contract and the plan had overturned the denial and reimbursed you.The Plan denied your request. The Plan says contracts are not a Medicare covered service. In addition, this provider does not participate in Medicare.The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider and supplier enroll in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the annual residential service contract have not been met.Therefore, we decided that the Plan does not have to pay for the annual residential service contract for the 2020 year purchased December 16,2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total hip arthoplasty for the enrollee.You asked the Plan to pre-approve the surgery. You say that this is medically necessary.The Plan denied your request. The Plan says the records do not show that the hip is badly worn out.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with complaints of severe back and right hip pain. Functional limitations are noted due to pain. The submitted hip exam documented no tenderness, normal strength, and limited but non-specific range of motion. There is no evidence of osteoarthritis on right hip x-rays or MRI. There are significant lumbar spine degenerative changes causing anterolisthesis with nerve root compromise at the L4/5 level. She has failed to achieve sustained improvement with activity modification, medications, physical therapy, and cortisone injection. It is noted that she had significant temporary pain reduction with a corticosteroid injection to the right hip. Under consideration is a request for right total hip replacement. Medicare coverage criteria have not been met. There is no evidence of advanced joint disease on x-rays and the right hip MRI is reported normal. She does have a history of unsuccessful conservative therapy and does not have any contraindications. She also has significant lumbar spine pathology which has not yet been fully evaluated. Given the absence of advanced right hip joint disease, this request for right total hip arthroplasty is not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgery have not been met.Therefore, we decided that the Plan does not have to pre-approve a total hip arthoplasty for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve corneal relaxing incision for correction of surgically induced astigmatism (65772) and extracapsular cataract removal with insertion of intraocular lens prosthesis (66984). You asked the Plan to pre-approve corneal relaxing incision for correction of surgically induced astigmatism and extracapsular cataract removal with insertion of intraocular lens prosthesis. You say that the requested services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 corneal relaxing incision for correction of surgically induced astigmatism and extracapsular cataract removal with insertion of intraocular lens prosthesis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the service of Limbal Relaxing Incision (LRI) is not medically necessary based on your diagnosis and medical records. There is no evidence from the record that you require anything more than cataract surgery and postoperative glasses to improve vision. Although theLRI provides you with better uncorrected vision, it is not medically necessary to improve you vision or functioning.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of corneal relaxing incision for correction of surgically induced astigmatism and extracapsular cataract removal with insertion of intraocular lens prosthesis have not been met.Therefore, we decided that the Plan does not have to pre-approve cornealrelaxing incision for correction of surgically induced astigmatism (65772) and extracapsular cataract removal with insertion of intraocular lens prosthesis (66984).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says your
condition does not require skilled services as an inpatient.
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.
Continued SNF services beyond June 11, 2020, were requested. 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 continued services. Our physician reviewer found that from a nursing perspective, you
had stable vital signs, and received oral medications. There are no identifiable skilled nursing service needs.
Regarding rehab services, you are at modified independent to contact guard assist with functional mobility.
You require varying assist with activities of daily living. Although there are identifiable skilled therapy service
needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of
illness or intensity of service criteria for an inpatient basis in a SNF 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 continued services have not been met. Therefore, we decided that the Plan does
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home sleep test (G0399).
You asked the Plan to pre-approve a home sleep test. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has already been diagnosed with OSA.
The Plan follows Medicare rules. Medicare rules say that more than one Home Sleep Test (HST) to establish the diagnosis of Obstructive Sleep Apnea (OSA) would not be expected. If more than one HST session is performed for suspected OSA, persuasive medical evidence justifying the medical necessity for the additional tests will be required. 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 home sleep test. Our reviewer says that the requested study is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of OSA, is currently on continuous positive airway pressure (CPAP) with reportedly good compliance and a normal Epworth score. There have been no major changes in body weight or other changes that would be expected to affect the OSA. Therefore, a repeat PSG is considered not medically necessary. Downloading of the CPAP data could establish whether the current CPAP settings are adequately treating the OSA. CPAP should be continued. The denial of a home PSG is upheld. 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 home sleep test have not been met. Therefore, we decided that the Plan does not have to pre-approve a home sleep test (G0399).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for 3D rendering (76376) provided on November 27, 2019.
You asked the Plan to pay for the 3D rendering. You say that you would like reconsideration as this service
was billed correctly. The Plan denied your request. The Plan says the related or qualifying service was not
identified on the claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 76376 is not supported in the record. Specifically, CPT code 76376 must be performed
and billed in conjunction with the base imaging procedure. Based on this information, we decided that
Medicare rules for coverage of the 3D rendering have not been met. Therefore, we decided that the Plan does
not have to pay for 3D rendering (76376) provided on November 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the DME purchased October 1, 2018 through November 16, 2018 from an out-of-network provider. You asked the Plan to reimburse for the DME. You say that you are requesting reimbursement of services rendered.The Plan denied your request. The Plan says the durable medical equipment is not medically necessary.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  Review of the file shows that you purchased reaching/grabbing device, any type, any length, each (A6549) and sales tax on October 01, 2018. This service is not a benefit under your plan.Review of the file shows that you purchased sales tax on October 03, 2018 from an out-of-network provider. The provider who rendered the service or supplied the item or supply is not an in-network provider and you do not have a referral from your Primary Care Physician for this service provider, so this is not covered by the Plan. Review of the file shows that you purchased a bed pan, standard, metal or plastic (E0275), gradient compression stocking/sleeve, not otherwise specified (A6549) and sales tax purchased on October 06,2018. This service is not a benefit under your plan. The member is responsible for payment of this denied service.The provider who rendered the service or supplied the item or supply is not an in-network provider and you do not have a referral from your Primary Care Physician for this service provider, so this is not covered by the Plan.Review of the file shows that you purchased durable medical equipment, miscellaneous (E1399), transfer device, any type, each (E0705), raised toilet seat (E0244) and sales tax (S9999) on October 15, 2018. This service is not a benefit under your plan. The provider who rendered the service or supplied the item or supply is not an in-network provider and you do not have a referral from your Primary Care Physician for this service provider, so this is not covered by the Plan. Review of the file shows that you purchased durable medical equipment, miscellaneous (E1399) and sales tax on November 16, 2018. This service is not a benefit under your plan. 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 reimburse for the DME purchased October 1, 2018 through November 16, 2018 from an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation.
You asked the Plan to provide coverage for additional routine transportation. You say that additional
transportation benefits are necessary. The Plan denied your request. The Plan says once this benefit is
exhausted it cannot be extended.
Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits,
they are not required to do so. Medicare does not provide exceptions to supplemental benefits. The Plan states
you have exhausted your 2020 routine transportation benefit. Therefore, we decided that the Plan does not have
to provide coverage for additional routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan has to pre-approvean oxygen concentrator (E1390) and portable oxygen (E0431)for 3 months. We decided that the Plan does not have to pre-approvethe portable oxygen and portable oxygen for 1 year. You asked the Plan to pre-approvean oxygen concentrator (E1390) and portable oxygen (E0431)for 1 year. You say that the oxygen concentrator and portable oxygen are medically necessary. The Plan says that guidelines for the oxygen concentrator and portable oxygen are not met.The Planmust follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen.  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 oxygen concentrator (E1390) and portable oxygen (E0431). Our physician reviewer found the recent BMI of 27.9 does not support the diagnosis of morbid obesity, and suggests the enrolleemay have lost substantial weight, with a possible change in the oxygen requirement.  This enrolleeneeds to have ambulatory oximetry and/or overnight oximetry to determine whether the enrolleestill needs supplemental oxygen.  It is reasonable and necessary to approve continued oxygen (concentrator and portable oxygen) for 3 months, to allow time to obtain this documentation. The denial is partially overturned.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of oxygen concentrator (E1390) and portable oxygen (E0431) for 3 months have been met. Therefore, we decided that the Plan has to pre-approve oxygenconcentrator and portable oxygenfor 3 months. We decided that the Planhas to pre-approvean oxygen concentrator (E1390) and portable oxygen (E0431)for three months. We also decided that the Plandoes not have to pre-approvean oxygen concentrator (E1390) and portable oxygen (E0431) for 1 year.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 toopen 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 Prolia (Denosumab).
You asked the Plan to pre-approve the Prolia (Denosumab). The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.
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 the Prolia (Denosumab). Our reviewer says that Prolia (Denosumab) does not meet the Plan's coverage criteria. Our physician reviewer found the enrollee has not tried and failed the required drug, Zoledronic Acid. Our reviewer also found that the documentation does not support that Zoledronic acid would likely be less effective, and/or would likely have adverse effects for the 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 the Prolia (Denosumab) have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (Denosumab).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided January 9 to January 16, 2020.You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care was medically necessary.The Plan denied your request. The Plan says that rules for coverage were not met.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to 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 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 January 9 to January 16, 2020.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 Prolia.
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your request. The Plan says Prolia is not medically necessary.
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 Prolia. Our reviewer says that Prolia is not medically necessary. Our physician reviewer found based on the medical records provided the documentation does not support that Prolia is medically reasonable and necessary for the enrollee. Important safety guidelines for use of the drug necessitate ruling out hypocalcemia prior to its administration. The most recent calcium level on this enrollee in the available records was over one year ago (02/26/2019). Also it is important that the enrollee be on adequate calcium and vitamin D replacement while using Prolia (1000 mg of calcium and at least 400 units of vitamin D daily), the provided medical records do not document this level of calcium and vitamin D replacement. Based on the medical records provided the documentation does not support that Prolia is safe and effective for the 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee does not have a condition covered for this treatment.
The Plan follows Medicare rules. Medicare rules say that hyperbaric oxygen therapy is only covered under certain medical 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 requested services. Our physician reviewer found that you have a diagnosis of anoxic brain injury related to cardiac arrest. Your neurologist documents that he sees no harm in performing hyperbaric oxygen treatments neurologically. The benefit is uncertain. You do not have a covered indication for HBO therapy. Therefore, the requested services are not medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy.