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

We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure device (CPAP).
You asked the Plan to pre-approve continued CPAP use. You say that you had a family emergency that caused you not to use your CPAP as often as possible. The Plan denied your request. The Plan says that continued CPAP use is only covered when documented compliance is noted.
The Plan must follow Medicare rules. Medicare rules say that you must use the PAP 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. We looked at the file and Medicare rules. The compliance report included with the file indicates you did not adhere to therapy. Based on this information, we decided that Medicare rules for coverage of continued CPAP use have not been met. Therefore, we decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure device (CPAP).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 5, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for office visit. You say that you do not understand why this provider was denied.
The Plan denied your request. The Plan says the denial of payment for this service is correct, because this
provider is out-of-network with the Plan and prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on December 5,
2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Libtayo (J9119).You asked the Plan to pre-approve Libtayo. You say that the medication is 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. 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 Libtayo. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the enrollee has squamous cell cancer from the buccal mucosa treated with surgery and radiation in 2017. The enrollee was diagnosed with recurrence in 2019 and underwent additional surgery and radiation. Review of Medicare compendia does not support the use of Libtayo for this enrollee's cancer type. Without the support of the documentation, medical necessity cannot be determined.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Libtayo have not been met.Therefore, we decided that the Plan does not have to pre-approve Libtayo (J9119).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department services provided on December 28, 2018.
You asked the Plan to pay for the emergency department services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were filed untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the emergency department services was not filed until January 1, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the emergency department services provided on December 28, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto for the enrollee.
You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Entresto for the enrollee.
Benefits for this drug 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlaboratory testing provided b\on July 15, 2019 and August 13, 2019.You asked thePlan to pay forlab tests. You say that you are appealing with records.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records stating exactly which tests were to be performed.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab tests billed. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met.Therefore, we decided that the Plan does not have to pay forlaboratory testing provided on July 15, 2019 and August 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveelectronic connection, expandable controller, and harness for a wheelchair for the enrollee.You asked the Planto pre-approvethe accessories. You say that this is medically necessary.The Plandenied your request. The Plansaysit is not medically necessary to control the three approved power options through the joystick/drive interface.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 accessories. Our reviewer says that the requested accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found these requests are convenience items and do not serve to allow the power mobility device to function or serve to markedly enhance MRADL function. As such, the accessories are 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 accessories have not been met.Therefore, we decided that the Plandoes not haveto pre-approveelectronic connection, expandable controller, and harness for a wheelchair for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) provided November 27, 2019.You asked the Plan to pay for the orthosis. You say that you disagree with the determination and request reconsideration due to medical necessity.The Plan denied your request. The Plan says the records do not support that the replacement of this brace was necessary due to loss or irreparable damage.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The records show that the enrollee had received the same item (L1833) from a different provider on date of service June 26, 2019. L1833 serves the same purpose as the orthosis.Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) provided November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for bladder irrigation provided at an outpatient hospital facility on November 13, 2019.
You asked the Plan to waive the copayment for bladder irrigation. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 a $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received bladder irrigation from an outpatient hospital facility on November 13, 2019. Bladder irrigation is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $250 copayment. You have been asked to pay a $250 copayment for bladder irrigation. Bladder irrigation falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 bladder irrigation provided at an outpatient hospital facility on November 13, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Emergency Room Visit on December 12, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 an $80 copayment for Emergency Care. You have been asked to pay an $80 copayment for the emergency room visit. The emergency room visit falls within the Emergency 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 copayment for an Emergency Room Visit on December 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Benicar 20mg tablet medication.You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says this medication is not a covered benefit under the enrollee's contractual policy.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve the Benicar 20mg tablet medication.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the vision services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the member does not have out-of-network benefits.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on November 19, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea power wheelchair with accessoriesYou asked the Planto pre-approvethe wheelchair. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not medically necessary.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the records do not indicate that you are unable to use a walker or other lesser device, such as a lightweight wheelchair.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 wheelchair have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea power wheelchair with accessories
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Kymriah.
You asked the Plan to pre-approve Kymriah. You say that the requested Kymriah is medically necessary. The Plan denied your request. The Plan says that the requested Kymriah is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Kymriah. Our reviewer says that the requested Kymriah is medically necessary. Our physician reviewer found this review relates to a request for Kymriah to treat a woman with secondary central nervous system relapse of previously systemic diffuse large cell B cell lymphoma after three prior regimens. The disease was diagnosed by breast biopsy in 2011 and has involved peripheral lymph nodes. The requested use is FDA approved. Per the FDA website, the drug is approved for adult patients with relapsed or refractory (r/r) large B-cell lymphoma after two or more lines of systemic therapy including diffuse large B-cell lymphoma (DLBCL) not otherwise specified, high grade B-cell lymphoma and DLBCL arising from follicular lymphoma. The request is 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 Kymriah have been met. Therefore, we decided that the Plan has to pre-approve Kymriah.
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 pay for eye exam (92004) refraction (92015) and fundus photography (92250) provided November 8, 2019.You asked the Plan to pay for the vision services. You say that you feel the network provider was using scare tactics to sell a surgery that would not have mattered and this provider offered better results and better customer service.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. Non-emergent services with non-contracted providers require prior-authorization prior to services being rendered. The plan confirmed that services were available in network.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when rendered by an in network provider.We looked at the file and the Plan's rules. Services provided by an out of network provider is not covered. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.Therefore, we decided that the Plan does not have to pay for eye exam (92004) refraction (92015) and fundus photography (92250) provided November 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of a foreign body (20525) and exploration (20103) of the left thumb to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve removal of a foreign body and exploration of the left thumb. You say that the enrollee does not want to have the procedure done in a hospital because of the Coronavirus and no in-network ambulatory surgery center is open. The Plan denied your request. The Plan says there are in-network facilities available. Therefore, coverage criteria has not been met.
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 care that cannot be provided by network providers. 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-approve removal of a foreign body (20525) and exploration (20103) of the left thumb to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Planhasto pre-approvegenetic testing for ataxia for the enrollee.You asked the Planto pre-approvethe testing. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthis testing is unlikely to impact therapeutic decision-making in the clinical management of the enrollee.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 testing. Our reviewer says that the requested services areconsidered medically reasonable and necessary in this case. Our physician reviewer found the hereditary ataxias are a genetically heterogeneous group of diseases that may be difficult to distinguish clinically, because they are all characterized by muscleincoordination. With the ability to identify the specific gene defects in many of these disorders, the diagnosis of hereditary ataxia is currently being made more and more often by genetic testing. It is documented in the Movement Center Department of Neurology Office Visit note dated 11/19/19 that identification of a specific ataxia would clearly change management of the enrollee, given the risk of cardiomyopathy and diabetes. It is documented in the Neuromuscular Disease Center Office Visit note dated 2/24/20 that genetic testing would be useful, and may in fact change the management. For example, it could prevent unnecessary diagnostic testing, and prevent expensive treatments that have potential side effects. The enrollee's neurologist writes that hereditary ataxias cannot be distinguished clinically from one another without genetic testing, and that genetic testing will help determine a health maintenance plan, recurrence risk, presymptomatic support, and family planning.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 testing have been met.Therefore, we decided that the Planhas to pre-approvegenetic testing for ataxia for the enrollee.If the Plandoes 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/orsend 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued weekly skilled nursing (SN) visits in the home health setting.You asked the Plan to pre-approve the weekly SN visits. You say that it is felt that ongoing SN visits are necessary to maintain your condition.The Plan denied your request. The Plan says the enrollee's condition is not such that SN visits are required at this time.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 weekly SN visits. Our reviewer says that the documentation does not support the medical necessity of weekly home SN visits. Our physician reviewer found the records do not show that the requested additional skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the patient's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. The documentation does not indicate that the patient's needs require a skilled nurse. His medical issues appear stable. The patient is able to take care of his ostomy, is compliant with blood sugar checks and recordings, compliant with medications, has controlled blood sugar, and is aware of his disease processes and when to report issues. There is no evidence of complex wound care or other new SN need. 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 weekly SN visits have not been met.Therefore, we decided that the Plan does not have to pre-approve continued weekly skilled nursing (SN) visits in the home health setting.