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

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided April 1, 2021.

You asked the Plan to pay for the orthosis. You say that this enrollee requested services utilizing access to telemedicine from the physician of their choice in an effort to address COVID-19 concerns. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines.

The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. 

A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided April 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on November 17, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for outpatient hospital services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring provider is also out-of-network.
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 had network providers available who could have provided 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 outpatient hospital services provided on November 17, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the office visit with an ophthalmologist (99213) provided on March 8, 2021.
You asked the Plan to waive the coinsurance for the office visit. You say that you would like reconsideration because you were told you would receive a free eye exam. The Plan denied your request. The Plan says the copayment applied for this service is correct.
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 $40 copayment for Medicare covered vision services rendered in a specialist's office.
You have been asked to pay a $40 copayment for the office visit. The ophthalmologist visit falls within the
Vision 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 coinsurance for the office visit with an
ophthalmologist (99213) provided on March 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for non-emergency ambulance transportation (A0428, A0425) provided on April 14, 2021.

You asked the Plan to waive the copayment for non-emergency ambulance transportation. You say that you were not aware that there would be a charge for the service at issue. The Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 copayment for ambulance services.

You have been asked to pay a $65 copayment for non-emergency ambulance transportation. The services at issue fall within the ambulance services 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 non-emergency ambulance transportation (A0428, A0425) provided on April 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found your medical conditions are stable and you do not have any complex nursing or rehabilitation needs. You do require physical and occupational therapy, but there is no documented need for an
intensive rehabilitation program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Specifically, medically necessary services are available at a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the vertiflex device (22867,22868).
You asked the Plan to pre-approve the vertiflex device. You say that the service is medically necessary. The Plan denied your request. The Plan says the 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 the vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the vertiflex device is experimental and needs more research on its 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 the vertiflex device have not been met. Specifically, there is not enough research showing the safety and efficacy of the device. This means that the service is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the vertiflex device (22867,22868)
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 you will be equally well-served at an alternate level of care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued services. Our physician reviewer found that from a nursing perspective, you received oral medications, had stable vital signs, and were treated for a urinary tract infection. There are no identifiable skilled nursing service needs. Regarding rehab services, you were at a supervision to standby assist level with functional mobility. You required varying assist with activities of daily living. There are no 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Actemra (tocilizumab).
You asked the Plan to pre-approve Actemra. You say that your doctor wants to switch you to a more effective
injection. The Plan denied your request. The Plan says you have not tried and failed Humira, Enbrel, Xeljanz,
or Rinvoq.
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 Actemra. Our physician reviewer found
that you have a diagnosis of Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or
systems involvement. You have been treated with Methotrexate, Prednisone, and Rituximab. The Plan requires
a trial of Humira, Enbrel, Xeljanz, or Rinvoq before they will approve the requested drug. The case file does
not contain documentation of a trial of the Plan's required drugs. The documentation does not support that the
Plan's required drugs would likely be less effective, or would likely have adverse effects.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Actemra have not been met. Therefore, we decided that the Plan does not have
to pre-approve Actemra (tocilizumab).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the peripheral nerve stimulator (64555).

You asked the Plan to pre-approve the peripheral nerve stimulator. You say that the service is medically necessary. The Plan denied your request. The Plan says that this service is not a covered Medicare benefit because acupuncture for auricular stimulation does not meet the definition of reasonable and necessary.

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 peripheral nerve stimulator. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has both neuropathic and phantom limb pain after bilateral above the knee amputations, the request is for peripheral nerve stimulation of the femoral and sciatic nerves, not auricular acupuncture. 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 peripheral nerve stimulator have been met. Therefore, we decided that the Plan has to pre-approve the peripheral nerve stimulator (64555).

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 (J0897).
You asked the Plan to pre-approve Prolia. You say that the drug is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet any of the criteria for this drug.
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 Prolia. Our reviewer says that the drug is not medically necessary. Our physician reviewer found the requested drug is not FDA approved for this enrollee's diagnosis and its use is not supported by an of the major drug compendia or clinical research.
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 (J0897).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient hospital admission.
You asked the Plan to pay for acute inpatient hospital admission. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee's symptoms resolved while being evaluated in the emergency room. The enrollee's primary care doctor was aware of the problem and would be following up with them.
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 not been met. Specifically, the record did not show 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. This means acute inpatient hospital care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pay for acute inpatient hospital admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 9, 2021 to February 10, 2021 by a non-participating provider.
You asked the Plan to pay for these services. You say that you were told by the doctor's office you were covered by insurance. The Plan denied your request. The Plan says the services were rendered by a non-participating provider without 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 had network providers available who could have provided 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. The Plan cannot be held responsible for possible misinformation given by a provider regarding network status.
Therefore, we decided that the Plan does not have to pay for the office visit provided on February 9, 2021 to February 10, 2021 by a non-participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor supplies provided on June 13, 2020.
You asked the Plan to pay for the therapeutic continuous glucose monitor supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee did not meet criteria for the items rendered.
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 the enrollee does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the therapeutic continuous glucose monitor supplies have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor supplies provided on June 13, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing.
You asked the Plan to pre-approve genetic testing. The Plan denied your request. The Plan says the request is not medically necessary.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. We looked at the file and the rules. The requested genetic testing is being requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Testing without signs, symptoms, or personal history of disease is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve genetic testing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve Intracept. You say that Intracept received Food & Drug Administration (FDA) clearance and there have been studies showing it is safe and effective. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies have not proven that this is helpful for treatment of the enrollee's condition.
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 Intracept. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Food & Drug Administration (FDA) has state that the Intracept Intraosseous Nerve Ablation System is intended to be used in conjunction with radiofrequency (RF) generators for the ablation of basivertebral nerves of the L3 through S1 vertebrae for the relief of chronic low back pain of at least six months duration that has not responded to at least six months of conservative care, and is also accompanied by features consistent with Type 1 or Type 2 Modic changes on a Magnetic Resonance Imaging (MRI) such as inflammation, edema, vertebral endplate changes, disruption and fissuring of the endplate, vascularized fibrous
tissues within the adjacent marrow, hypointensive signals (Type 1 Modic change), and changes to the vertebral body marrow including replacement of normal bone marrow by fat, and hyperintensive signals (Type 2 Modic change). In this case, the record indicates that the enrollee has low back pain that has not responded to conservative treatment. The provided MRI does not indicate the presence of Modic type changes. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist telehealth services provided by a
participating provider on February 8, 2021.
You asked the Plan to waive the copayment for specialist telehealth services. You say that you were asked 5
questions. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the
correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45
copayment for physician/practitioner services/in-network/specialist.
You have been asked to pay a $45 copayment for specialist telehealth services. Specialist telehealth services fall within the physician/practitioner services/in-network/specialist 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 specialist telehealth services provided by a participating provider on February 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for testing for cyanocobalamin (82607), testosterone (84403), and free thyroxine (84439) provided on February 1, 2021.
You asked the Plan to pay for testing for cyanocobalamin, testosterone, and free thyroxine. You say that these tests should be covered. The Plan denied your request. The Plan says these were performed for screening purposes.
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 testing at issue in this appeal, testing for cyanocobalamin, testosterone, and free thyroxine, was requested 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 testing for cyanocobalamin (82607), testosterone (84403), and free thyroxine (84439) provided on February 1, 2021.