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

We decided that the Plan does not have to pre-approve non-sterile disposable gloves.
You asked the Plan to pre-approve non-sterile disposable gloves. You say that you need gloves for protection from Covid-19. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that non-sterile disposable gloves are not covered because they are hygienic items that are non-reusable. While non-sterile disposable gloves may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Non-sterile gloves are only covered by Medicare for dialysis services or home health services packages. Therefore, we decided that the Plan does not have to pre-approve non-sterile disposable gloves.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the oral sleep apnea appliance to be provided by an out
of network provider.
You asked the Plan to pre-approve the oral sleep apnea appliance. You say that there is no in-network provider
available. The Plan denied your request. The Plan says the service requested is available from participating
providers in the enrollee's service area.
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
the oral sleep apnea appliance to be provided by an out of network provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the lab services (CPT 87633) provided on February 25, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that this is non-covered service.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan says that this service is not covered by Medicare according to LCA A57579. LCA A57579 does not indicate that the requested service or CPT code is non-covered. A57579 indicates that there are certain coding rules that must be met for coverage of CPT code 87633. The plan has not shown that the coding rules have not been followed. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the lab services (CPT 87633) provided on February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for venipuncture (36415) and a preventive physical examination (G0402) provided on December 31, 2019.
You asked the Plan to pay for the venipuncture and preventive exam. You say that you would reconsideration and you are working with the Health Plan and providers to straighten out this issue. The Plan denied your request. The Plan says they cannot pay the claim until the other insurance Explanation of Benefits is received.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested the primary insurer's Explanation of Benefits. As the secondary insurer, the Plan cannot be held responsible for the venipuncture and preventive exam until the primary insurer has denied the claim for these services.
Therefore, we decided that the Plan does not have to pay for venipuncture (36415) and a preventive physical examination (G0402) provided on December 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 7, 2020 by an out of network (OON) provider.You asked the Plan to pay for the portable x-ray services. You say that you would like reconsideration because you should not be required to absorb the cost of providing care to patient's that have no ability to request prior authorization for out-of-network care.The Plan denied your request. The Plan says non-urgent services should be from network providers who are contracted with the member's health plan 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 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 February 7, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on March 5, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 laboratory services provided on March 5, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued home health services.You asked the Plan to pre-approvethe services. You say that this is medically necessary, as services are still needed.The Plan denied your request. The Plan says the clinical information submitted does not establish medical necessity.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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found based on the medical records provided the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or toestablish/perform a maintenance program to maintain your condition and/or prevent deterioration.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued home health services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SPRAVATO.
You asked the Plan to pre-approve SPRAVATO. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the requested drug is not a covered benefit.
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 SPRAVATO.
Benefits for SPRAVATO 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair accessory, push-rim activated power assist system.You asked the Plan to pre-approve a manual wheelchair accessory, push-rim activated power assist system (E0986). You say that the wheelchair assist would keep you from getting stranded and give you more mobility to bring your chair anywhere with anyone and in different vehicles.The Plan denied your request. The Plan says the record shows you have trunk weakness and cannot safely operate the item requested.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The record shows you have sufficient upper extremity functionto self-propel a manual wheelchair in the home to perform your MRADLs. This accessory is being requested for use outside the home and therefore is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of a manual wheelchair accessory, push-rim activated power assist system (E0986) have not been met.Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair accessory, push-rim activated power assist system.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydrochlorothiazide Tab.You asked the Plan to pre-approve Hydrochlorothiazide Tab. You say that you want the enrollee to be treated with this drug.The Plan denied your request. The Plan says this drug is not covered under Medicare 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 Hydrochlorothiazide Tab.Benefits for Hydrochlorothiazide Tab may be available under Medicare PartD. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the services (CPT 27759) provided on March 4, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the MUE value for this service is 1.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan says that the maximum allowable units for CPT 27759 was exceeded for the date of service in question. The MUE value for CPT 27759 is 1. The records show that 1 unit of CPT 27759 was billed for March 4, 2020. This does not exceed the maximum allowable units for CPT 27759. The plan has not provided documentation to substantiate its denial. Therefore, we decided that the Plan has to pay for the services (CPT 27759) provided on March 4, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelaminectomy surgery.You asked the Plan to pre-approvelaminectomy. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this surgery 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 laminectomy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not show any evidence of severe stenosis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of laminectomy have not been met.Therefore,we decided that the Plan does not have to pre-approvelaminectomy surgery.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a Computed Tomography (CT) scan of the sinus (77011).
You asked the Plan to pre-approve the CT scan. You say that the CT of the sinus is medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the requested procedure is medically necessary. Our physician reviewer found a CT of the sinus for stereotactic localization will be thinner cuts compared to a CT of the head. This is critical when planning for a surgical procedure or evaluating sinus pathology. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have been met. Therefore, we decided that the Plan has to pre-approve a Computed Tomography (CT) scan of the sinus (77011).
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the 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 they are 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 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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Carboplatin, Dexamethasone, and Granisetron IV.
You asked the Plan to pre-approve Carboplatin, Dexamethasone, and Granisetron IV. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested drugs are 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 Carboplatin, Dexamethasone, and Granisetron IV. Our reviewer says that the documentation supports that the requested drugs are medically reasonable and necessary. Our physician reviewer found the enrollee has pancreatic cancer and metastatic prostate cancer. The enrollee has had several prior lines of therapy and is now being recommended carboplatin and olaparib which was started on March 28, 2019. The use of Carboplatin, Dexamethasone, and Granisetron IV are not FDA-approved for the enrollee's diagnosis, however, the use is supported by one of the major drug compredia or by clinical research that appears in a CMS-approved medical journal. Therefore, the enrollee meets criteria for the requested drugs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Carboplatin, Dexamethasone, and Granisetron IV have been met. Therefore, we decided that the Plan has to pre-approve Carboplatin, Dexamethasone, and Granisetron IV.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve maxillary (upper) partial dentures.
You asked the Plan to pre-approve maxillary partial dentures. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item exceeds your benefit limit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers maxillary partial dentures when the services are medically necessary and reasonable. We looked at the file and Medicare rules. Dentures are covered once every 60 months. Review of the file shows that you received dentures on December 30, 2015. Sixty (60) months have not passed since you previous received dentures. Based on this information, we decided that the Plan's rules for coverage of maxillary partial dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve maxillary (upper) partial dentures.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on December 31, 2019. You asked the Plan to pay for lab tests. You say that you are attempting to straighten this issue out with your providers and your primary insurance carrier. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this claim cannot be processed by the Plan until the primary insurance explanation of benefits is received. The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has instructed you to submit the explanation of benefits from your primary insurance carrier. As the secondary insurer, the Plan cannot be held responsible for lab tests until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an epidural injection provided on February 18, 2020.
You asked the Plan to waive the copayment for an epidural injection. You say that you do not know why you were sent out-of-network and disagree with the high 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 $325 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $325 copayment for an epidural injection. An epidural injection 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 an epidural injection provided on February 18, 2020.