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

We decided that the Plan does not have to pay for a portable gaseous oxygen system provided on June 21, 2020. You asked the Plan to pay for the portable gaseous oxygen system. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization. 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 portable gaseous oxygen system. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for a portable gaseous oxygen system provided on June 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ofev 150 mg capsule.

You asked the Plan to pre-approve Ofev. You say that this service is medically necessary. The Plan denied
your request. The Plan says this medication does not fall under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Ofev 150 mg capsule.

Benefits for Ofev 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 19, 2020.
You asked the Plan to pay for the dental service. You say that you called the plan to find out coverage for an implant. You say that you were advised by a plan representative to go to an in-network dentist to get better coverage. You say that the estimate was more money, additional x-rays and a waste of time. You say that you feel you were misinformed by the plan representative. You also say that you live on a tight budget. The Plan denied your request. The Plan says 2 oral exams are covered per calendar year. The Plan says that the frequency limit has been exceeded.
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 frequency limit of 2 oral exams per calendar year has been exceeded. The record shows that the Plan paid for oral exams that you received on March 30, 2020, and September 1, 2020. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services.

You asked the Plan to waive the copayment for the laboratory services. You say that you would like reconsideration because this was part of your physical and you should not be charged. The Plan denied your request. The Plan says you are responsible for a $20.00 copayment per visit for laboratory tests.

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 outpatient diagnostic tests.

You have been asked to pay a $20 copayment for the laboratory services. The lab 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 laboratory services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the back surgery provided on August 14, 2020. You asked the Plan to reduce the coinsurance for the back surgery. You say that you should not be responsible for this amount because it was not your fault the battery needed to be replaced. You say it was agreed that you would pay $150 for the surgery. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount. 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 20% coinsurance for surgery performed at an in-network outpatient hospital facility. You have been asked to pay $2,352.80 which is 20% of the allowed amount for the back surgery. The allowed amount is $11,764. ($11,764 x 20% = $2,352.80). The back surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical center" 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 reduce the coinsurance for the back surgery provided on August 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D6010, D6104, D6056, D6060).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 Plan does not have to pre-approve dental services (D6010, D6104, D6056, D6060).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary.
The Plan denied your request. The Plan says the enrollee must try and fail Orthovisc and Synvisc/Synvisc One
first.
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 the
Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has a diagnosis of
Unilateral primary osteoarthritis of the right knee. The case file does not contain documentation of trial and
failure of Orthovisc and Synvisc/Synvisc One. The documentation does not support that Orthovisc and
Synvisc/Synvisc One would likely be less effective, and/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-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-sterile gloves (A4927, 100 per box).
You asked the Plan to pre-approve the gloves. You say that this is needed to change the catheter. The Plan denied your request. The Plan says Medicare does not cover non-reusable disposable supplies for home use.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve non-sterile gloves (A4927, 100 per box).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 therapeutic continuous glucose monitor
(CGM) receiver and supplies.
You asked the Plan to pre-approve a CGM receiver and supplies. You say that this is medically necessary. The
Plan denied your request. The Plan says that you do not meet criteria for these items.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that you do not have diabetes. Based on
this information, we decided that Medicare rules for coverage of a CGM receiver and supplies have not been
met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 therapeutic continuous
glucose monitor (CGM) receiver and supplies.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc 850 for the enrollee.

You asked the Plan to pre-approve Genvisc 850. You say that this is medically necessary. The Plan denied your request. The Plan says that the member has not tried and failed the preferred step therapy devices.

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 Genvisc 850. Our reviewer says that Genvisc 850 is not medically reasonable and necessary for the enrollee. The patient has not tried and failed Orthovisc and Monovisc. There is no indication that Orthovisc and Monovisc would likely be less effective and/or likely have adverse effects for the patient. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Genvisc 850.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Genvisc 850 have not been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc 850 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization
device (22869, 22870).

You asked the Plan to pre-approve this service. You say that this service is medically necessary for the
treatment of lumbar spinal stenosis. The Plan denied your request. The Plan says this service is not medically
necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer
found that the interlaminar device is experimental. More research is needed to show safety and efficacy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not
have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination, chest, provided on October 22, 2020.
You asked the Plan to pay for Radiologic examination, chest; 2 views (71046-26). You say that the procedure was performed at the request of the referring doctor. The Plan denied your request. The Plan says screening for lung cancer with chest x-rays once or regular intervals is not recommended by the American College of Chest Physicians and the American College of Radiology.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, Radiologic examination, chest; 2 views (71046-26), was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the radiologic examination, chest, provided on October 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the tissue removal surgery provided on August 17, 2020.
You asked the Plan to waive the deductible for the tissue removal surgery. You say that you were told you would have a $295 copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,000 deductible that applies towards outpatient surgery and a $295 copayment for each in-network Medicare-covered outpatient surgery in an outpatient hospital after you pay your $1,000 deductible. The tissue removal surgery you asked the Plan to waive the deductible for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible that applies towards outpatient surgery and a $295 copayment for each in-network Medicare-covered outpatient surgery in an outpatient hospital after you pay your $1,000 deductible. See chart below.
Date of Service
Service
Allowed Amount
Deductible/Copayment
Member Liability
August 17, 2020
Tissue removal surgery
$1,302.98
$1,000
$1,000
$302.98 (This is the remaining allowed amount)
$295
$295
Total
$1,295
This cost sharing is a contractual obligation that had not been met at the time the tissue removal surgery was received on August 17, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the tissue removal surgery provided on August 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-elbow-wrist-hand orthosis (L3960) provided on September 5, 2020.
You asked the Plan to pay for a shoulder-elbow-wrist-hand orthosis. You say that the enrollee is using the requested medically necessary item with benefit. The Plan denied your request. The Plan says rules for payment have not been met because there is insufficient documentation of a physician's examination.
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 pay for a shoulder-elbow-wrist-hand orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was chronic right shoulder pain. The documentation in the case file does not support that the requested shoulder/arm orthosis was medically reasonable and necessary for the enrollee in this case. A physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is insufficient documentation of a credible physical examination of the shoulder. 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 shoulder-elbow-wrist-hand orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a shoulder-elbow-wrist-hand orthosis (L3960) provided on September 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc (J7324).
You asked the Plan to pre-approve the Orthovisc. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says to be covered under Medicare Part B, this drug must be furnished by a physician.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Orthovisc (J7324).
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 requested LTACH admission is medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is 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 the LTACH services. Our reviewer says that the requested LTACH admission is not medically necessary. Our physician reviewer found the enrollee appears to be more stable and improving but still requires additional short-term acute care services to treat the infection and encephalopathy which can safely be received in the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CPAP device (E0601).
You asked the Plan to pre-approve a CPAP device. You say that the enrollee has a need for the requested equipment. The Plan denied your request. The Plan says criteria for pre-approval have 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 a CPAP device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was started on auto-CPAP after a home sleep study in August 2020. At clinical follow-up on October 28, 2020, compliance was excellent. However, a compliance report covering November 4, 2020, to February 1, 2021, showed only 8% of days with at least 4 hours of use, which does not meet minimum Medicare criteria of at least 70% of days. The records do not include any further follow-up visits to address the compliance issue. CPAP is considered not medically necessary because usage of the device is not sufficient to provide benefit. 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 CPAP device have not been met. Therefore, we decided that the Plan does not have to pre-approve a CPAP device (E0601).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an LSO (L0650) provided on September 19, 2020.
You asked the Plan to pay for an LSO. You say that the enrollee is using the requested medically necessary item with benefit. The Plan denied your request. The Plan says rules for payment have not been met because the record contains insufficient documentation of a physician's examination.
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 pay for an LSO. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was lower back pain. The available documentation in the case file does not support that the requested LSO was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the LSO was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the back. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an LSO have not been met. Therefore, we decided that the Plan does not have to pay for an LSO (L0650) provided on September 19, 2020.