Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tyavso solution for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria was not 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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has 
pulmonary arterial hypertension (PAH) as well as chronic obstructive pulmonary disease (COPD) and 
interstitial lung disease (ILD). Among the criteria that must be met for this drug: the criteria were not met. "The 
pulmonary hypertension is not secondary to pulmonary venous hypertension (e.g., left sided atrial or 
ventricular disease, left sided valvular heart disease, etc.) or disorders of the respiratory system (e.g., chronic 
obstructive pulmonary disease, interstitial lung disease..." The enrollee's PAH appears to be secondary to 
COPD and ILD, so this criterion is not met. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tyavso solution for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiography (TTE) test.

You asked the Plan to pre-approve TTE test. You say that you are having strong pains and are concerned. The
Plan denied your request. The Plan says the denial of authorization for this service is correct, because the
clinical information does not show new or changing signs/symptoms, or abnormal heart exam or heart rhythm
to support this testing.

The Plan follows Medicare rules. Medicare rules state that TTE testing may be covered for evaluation under
certain circumstances.

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 TTE test. Our reviewer says that you do
not meet the Medicare criteria for this TTE test. Our physician reviewer found the documentation indicates that
you feel you need this service because you are having strong sharp pains. The available clinical information
does not show new or changing signs or symptoms, or abnormal heart examination or heart rhythm to support
this request.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of TTE test have not been met. Therefore, we decided that the Plan does not have
to pre-approve a transthoracic echocardiography (TTE) test.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Denosumab. 
 
You asked the Plan to pre-approve Denosumab. You say that the medical records support that the requested 
drug is medically reasonable and necessary. The Plan denied your request. The Plan says the records provided 
do not show that the enrollee meets the criteria for coverage of the requested drug. 
 
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 Denosumab. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee had a T-score of -2.3. The 
enrollee does not have osteoporosis based on the information provided and the requested drug would not be 
indicated, reasonable, or medically necessary for this patient. It is not clear that Denosumab would be safe and 
effective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Denosumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Denosumab.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the inpatient hospital admission from April 30, 2021, to May 1, 2021.
You asked the Plan to reduce the copayment for the inpatient hospital admission. You say that you were never an inpatient and should only be charged the Emergency Room copayment. The Plan denied your request. The Plan says the medical records and the approved inpatient authorization on file with the Plan show that you were admitted as an inpatient and 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 $260 copayment for each day for days 1-7 of a covered inpatient stay during a benefit period.
You have been asked to pay a $260 copayment for the inpatient hospital admission. The Plan provided documentation from the hospital showing that you were admitted as an inpatient. This inpatient hospital admission falls within the Inpatient hospital 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 reduce the copayment for the inpatient hospital admission from April 30, 2021, to May 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dysport.
You asked the Plan to pre-approve Dysport. You say that the enrollee has been using 500 units of Dysport for migraines. You say that the enrollee did not respond to Botox. The Plan denied your request. The Plan says the use of Dysport for migraines is considered investigational.
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 Dysport. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee is noted to have a history of chronic migraine headaches. They have previously been treated with Dysport for prophylaxis with reported benefit. However, the drug is not being used for an FDA approved indication or a diagnosis supported in the compendia. No practice guidelines recommend the use of this specific neurotoxin in migraines. There is otherwise a lack of evidence from well-designed studies to support the use of Dysport in migraine. As such it cannot be determined to be reasonable and 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 Dysport have not been met. Therefore, we decided that the Plan does not have to pre-approve Dysport.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoroscopic guidance rendered on February 4, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 77003 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 77003 is fluoroscopic guidance and localization of needle 
or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or 
subarachnoid) (List separately in addition to code for primary procedure). 
 
We find that CPT code 77003 is not supported in the medical record. Specifically, this is an add-on code that 
was not billed with a required primary procedure code. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the fluoroscopic guidance rendered on February 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hymovis.

You asked the Plan to pre-approve Hymovis. You say that the requested Hymovis is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Orthovisc, Synvisc, or 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 Hymovis. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of Orthovisc, Synvisc, or Synvisc-One first before they will approve the requested drug. In this case the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hymovis have not been met. Therefore, we decided that the Plan does not have to pre-approve Hymovis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay from March 7, 2021, to March 24, 2021.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you received poor care at the hospital which caused you to stay longer than you should have. The Plan denied your request. The Plan says the copayment was applied correctly. Your quality of care concerns are being reviewed and addressed separately.
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 $300 copayment per admission after the deductible is met for each medically necessary inpatient stay. You have been asked to pay a $300 copayment for the inpatient hospital stay. This hospital stay falls within the Inpatient hospital 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. The Plan is reviewing your quality of care concerns separately. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital stay from March 7, 2021, to March 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, emergency transport (A0427) provided November 14, 2020.

You asked the Plan to waive the copayment for the ambulance transport. You say that your ambulance transport was related to Coronavirus and therefore you should not have a copayment. 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 $300 copayment for each one-way Medicare-covered ambulance trip. 

You have been asked to pay a $300 copayment for the ambulance transport. This ambulance transport falls within the Ambulance services benefit category. The Center for Medicare Services (CMS) issued a Coronavirus waiver to allow the Plan flexibilities to modify requirements. Ambulance copayments are not among those items listed on the waiver. 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 the ambulance service, advanced life support, emergency transport (A0427) provided November 14, 2020.

Your complaint about potentially receiving misinformation about coverage related to Coronavirus is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81407, 81408, 81286, 81479, 81404) provided 
October 22, 2020. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular 
risk assessment panels. 
 
We looked at the file and Medicare rules. The service at issue is a cardiovascular risk panel and is non-covered. 
Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (81407, 81408, 81286, 81479, 81404) 
provided October 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the office visits you had with a pain 
management specialist, and lab services from January 28, 2020, to May 18, 2021. 
 
You asked the Plan to waive the cost sharing for the specialist visits and lab services. You say that you see a 
pain management specialist once a month and the costs are difficult for you financially.  You believe these 
services should be covered 100%. The Plan denied your request. The Plan says You were charged these 
copayments 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 $30 
copayment for specialist visits and a $15 copayment for lab tests. 

Records show that during the dates of service in question, you had 16 specialist visits with this provider and 
five lab tests. You have been asked to pay a $30 copayment for each of the specialist visits and a $15 
copayment for each of the lab services. 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 cost sharing for the office 
visits you had with a pain management specialist, and lab services from January 28, 2020, to May 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you have a weak bladder. 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 incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on August 28, 2020.
You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says hearing aids are not covered when purchased outside of the Plan's hearing aid provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on August 28, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee on February 2, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the claim was submitted with codes S1015 and S8301 which have a status indicator of "I" which prohibits payment on Medicare claims.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the codes submitted have a status indicator which indicates Medicare uses another code to report these services. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee on February 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided September 23, 2020.

You asked the Plan to pay for the comprehensive oral exam. You say that you were not satisfied with the service and would like the Plan to reverse the claim payment. The Plan denied your request. The Plan says you have exceeded frequency limits for the service and therefore it is not covered.

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 the comprehensive oral exam once every three years. 

We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral exam provided January 11, 2021 has already been covered by the Plan. Based on this information, we determined that the Plan's frequency limit for the comprehensive oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided September 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible applied towards the dermatology office visit you had on March 1, 2021.
You asked the Plan to waive the deductible applied towards the dermatology office visit. You say that you have never had to pay anything to go to the doctor. The Plan denied your request. The Plan says this deductible was assessed correctly. The Plan says that you had not met your deductible at the time of this service.
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 $203 annual deductible for Part B services. The deductible applies to the dermatology visit you had. You had not yet met your annual deductible at the time of these services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $203 annual deductible for Part B services. Therefore, we decided that the Plan does not have to waive the deductible applied towards the dermatology office visit you had on March 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from August 28, 2020, to August 29, 2020.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you have a primary insurer and you carry insurance with this Plan as your supplement. You stated that you have never had to pay cost sharing for hospitalizations in the past. The Plan denied your request. The Plan says this copayment was charged correctly. The Plan says that because the remaining amount due after the primary insurer paid the claim is less than your copayment obligation under this Plan, you are responsible for the full remaining amount ($118.64).
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 $300 copayment a day for days 1-5 for inpatient hospital services. You have been asked to pay a the remaining balance of $118.64 towards $300 copayment a day for days 1-5 for the inpatient hospital services. Please note that this Plan is NOT a supplemental insurance plan--it is a Medicare Advantage Plan. Medicare Advantage Plans are permitted to charge cost sharing for services, even if they are the secondary payer. 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 inpatient hospital services provided from August 28, 2020, to August 29, 2020.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at a different level of care. 
 
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 based on the medical records provided the complexity of the enrollee's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an 
IRF level of care. 
 
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. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.