Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve use of Prolia.
You asked the Plan to pre-approve Prolia. You say that the enrollee has gastrointestinal issues and is on an
over-the-counter proton pump inhibitor, so oral bisphosphonates are contraindicated. The Plan denied your
request. The Plan says that the denial of authorization for Prolia is correct, because the enrollee has not tried
and failed oral bisphosphonates and does not have a history of osteoporotic fracture.
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 Prolia. Our reviewer says that the
enrollee meets the Medicare criteria for Prolia. Our physician reviewer found the enrollee has osteoporosis and
has tried and failed oral bisphosphonate therapy. Prolia is medically reasonable and necessary for the enrollee.
The documentation supports that the requested Prolia is 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 Prolia have been met. Therefore, we decided that the Plan has to pre-approve
use of Prolia.
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: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for closed Ostomy pouch with flange (A5054) Ostomy skin barrier, with flange (A4415) provided by September 13, 2019.
You asked the Plan to pay for the ostomy supplies. You say that according to Medicare Guidelines this was denied in error and you wish to appeal the denial of this claim. The Plan denied your request. The Plan says that The requested items are not covered by Medicare. The Medicare National Coverage Determinations (NCD) Manual provides a list of items that are non-covered with the reason for denial.
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 did not give a valid denial rationale. Ostomy supplies are covered by Medicare. However, they are not covered as durable medical equipment. As noted Ostomy supplies are covered under the prosthetic device benefit. The records also state that the supplies was ordered by a participating provider for the enrollee with a significant medical history of Colostomy status. Therefore, we decided that the Plan has to pay for closed Ostomy pouch with flange (A5054) Ostomy skin barrier, with flange (A4415) provided by September 13, 2019.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sensors for a continuous glucose monitor.
You asked the Plan to pre-approve the sensors for a continuous glucose monitor. You say that the enrollee is not using insulin injections or a continuous subcutaneous insulin infusion pump. The Plan denied your request. The Plan says the records provided do not support that the requested items are medically reasonable and necessary.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The sensors you have requested are not covered under Medicare because they are not considered to serve the medical purpose of making diabetes treatment decisions. In addition, there were no medical records supplied by the provider, despite the plan having made reasonable attempts to obtain this information. Therefore, we decided that the Plan does not have to pre-approve sensors for a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous passive motion (CPM) device and a cold circulating water pump.
You asked the Plan to pre-approve the CPM and cold water pump. You say that these devices will help with your recovery and reduce the need for physical therapy. The Plan denied your request. The Plan says these are not covered.
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery. Cold water pumps are also not considered medically necessary. You have not had total knee replacement surgery. Although both the pump and the CPM may be helpful, these are not covered by Medicare for your condition. Therefore, we decided that the Plan does not have to pre-approve a continuous passive motion (CPM) device and a cold circulating water pump.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for progressive lenses and anti-reflective coating provided on
October 9, 2019.
You asked the Plan to reimburse you for the progressive lenses and anti-reflective coating. The Plan denied your request. The Plan says deluxe eyewear is not a covered benefit.
Medicare rules say that progressive lenses will be denied as non-covered. Medicare rules say that that anti-reflective coating are covered only when they are medically necessary for the individual beneficiary and the medical necessity is documented by the treating physician. When these features are provided as a beneficiary preference item and are billed with an EY modifier they will be denied as not reasonable and necessary. Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. We looked at the file, Medicare's rules and the Plan's rules. Medicare does not cover progressive lenses. Medicare only covers anti-reflective coating when documented by the treating physician as medically necessary. The file does not contain documentation from the treating physician to substantiate Medicare's coverage criteria for the anti-reflective coating. The file shows that you purchased deluxe eyewear, which is not a Plan-covered vision benefit. Therefore, we decided that the Plan does not have to reimburse you for the progressive lenses and the anti-reflective coating provided on October 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Guardant360 testing for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing is covered when specific criteria are met. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of stage IV metastatic squamous cell carcinoma of the middle lobe, bronchus, or lung. PD-L1 expression is positive. The enrollee is not an untreated patient at the time of diagnosis. There is no documentation that EGFR single nucleotide variants (SNVs) and (insertions and deletions (indels); rearrangements in ALK and ROS1; or SNVs for BRAF are not available, AND that tissue-based CGP is infeasible. There is no documentation that the enrollee has had progression on treatment. The Guardant360 testing is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Guardant360 testing for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says there are no skilled needs identified.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. 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 skilled nursing facility 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation.
You asked the Plan to pre-approve routine transportation. You say that you need a ride to your appointment to see your surgeon. The Plan denied your request. The Plan says that neither Medicare nor the Plan cover routine transportation.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the bed rail, handheld shower head, and raised toilet seat.
You asked the Plan to reimburse you for bed rail, handheld shower head, raised toilet seat. You say that you need these items for safe entrance and exit to the bathroom and bedroom. The Plan denied your request. The Plan says these items are not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Medicare does not cover home modifications of shower heads. The bed rail is not on a covered hospital bed. Also, the items at issue in this appeal were provided in a non-urgent, non-emergent situation by Amazon.com. This provider has opted out of the Medicare program. The file shows that Amazon.com entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to reimburse you for the bed rail, handheld shower head, or raised toilet seat.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a capsule endoscopy for the enrolle.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show the enrollee has had complaints of flare of abdominal pain, nausea, and vomiting once a year. A computed tomography (CT) scan on September 2, 2019 showed no acute pathology. There is no radiologic or endoscopic evidence to support an ongoing suspicion of Crohn's disease. Furthermore, the suspicion or past history of bowel obstruction is a contraindication to the requested capsule endoscopy service. The capsule endoscopy is not reasonable or medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a capsule endoscopy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the FreeStyle Libre 14 day reader and sensor for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the requested product was determined to not be reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. 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 the provided documentation does not show that the continuous glucose monitoring system will be used in place of a blood glucose monitor for the enrollee for making diabetes treatment decisions (for example, changes in diet and insulin dosage) - the enrollee is not on insulin. 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-approve the FreeStyle Libre 14 day reader and sensor for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cialis.
You asked the Plan to pre-approve Cialis. The Plan denied your request. The Plan says this is not a Part B 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 Cialis.
Benefits for Cialis 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an out-of-network office visit. You say that this provider performed your previous transplant. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 an office visit to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea lip reduction, forehead lift, and reducing/reshaping of the nose.You asked the Plan to pre-approvethese services. You say that the services are necessary to complete gender confirmation.The Plan denied your request. The Plan says the services are cosmetic in nature and not covered.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have requested a lip reduction, forehead lift and reducing/reshaping nose for gender confirmation procedures. There are no photographs in the submitted documentation. Photographs are needed to adequately assess if the services are cosmetic or reconstructive in nature. The services are not medically necessary based on the submitted documentation.We looked at this physician's review, the file, and Medicare rules. 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 pre-approvea lip reduction, forehead lift, and reducing/reshaping of the nose.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are no 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 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 a referral to an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology tests provided on August 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for molecular pathology tests. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was obtained for these services.
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 molecular pathology tests provided on August 15, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve office services. You say that you will be in North Carolina and would like to see this provider. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network provider.
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 medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for radiological supervision and interpretation of an x-ray (72275), radiation exposure (G9500), an epidural injection (64483), and an iodine concentration (Q9966) provided on February 25, 2019 by the out of network provider.
You asked the Plan to pay for radiological supervision and interpretation of an x-ray, radiation exposure, an epidural injection, and an iodine concentration. You say that around January 20, 2019, you cancelled your contract with your health plan so you could return to another health plan. The Plan denied your request. The Plan says you talked with a  representative but by Centers for Medicare & Medicaid Services (CMS) regulations, you could not dis-enroll unless you sent a written request. You did that and mailed it with a postmark of February 4th. Since you were enrolled with the previous healthcare when these services were provided, the services could have been provided in-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 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 radiological supervision and interpretation of an x-ray (72275), radiation exposure (G9500), an epidural injection (64483), and an iodine concentration (Q9966) provided on February 25, 2019 by the out of network provider.