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

We decided that the Plan has to pay for the therapeutic continuous glucose monitor supply allowance provided on January 15, 2021.
You asked the Plan to pay for the supply allowance. You say that the Plan should pay this claim. The Plan denied your request. The Plan says that they cannot determine how the enrollee came to the servicing provider or whether the services are medically necessary.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered reasonable and necessary for enrollees with diabetes who meet criteria referenced above. We looked at the file and Medicare rules. There is a physician order for the CGM and supplies, and the medical record shows the enrollee is insulin treated with multiple injections and uses a CGM. Based on this information, we decided that Medicare rules for coverage of the supply allowance have been met. Therefore, we decided that the Plan has to pay for the therapeutic continuous glucose monitor supply allowance provided on January 15, 2021.
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: Favorable

We decided that the Plan has to pre-approve Palonestron.

You asked the Plan to pre-approve Palonestron. You say that this is medically necessary. The Plan denied your request. The Plan says that this would be a duplicate therapy based on the enrollee's current drug regimen.

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 Palonestron. Our reviewer says that the requested drug is medically necessary for the enrollee's condition. Our physician reviewer found the enrollee is a 66-year-old with triple negative breast cancer. In this case, there is no evidence the enrollee is currently receiving Palonestron in combination with another drug. Palonestron is FDA-approved for the enrollee's condition. The requested drug is safe and effective and otherwise reasonable and necessary for this 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 Palonestron have been met. Therefore, we decided that the Plan has to pre-approve Palonestron.

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 Farxiga 5mg tablets.

You asked the Plan to pre-approve Farxiga. You say that the Farxiga is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical 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 Farxiga 5mg tablets.

Benefits for Farxiga 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 pay for the orthosis provided March 24, 2021.
You asked the Plan to pay for the orthosis. You say that coverage for all telemedicine modalities is allowed. The Plan denied your request. The Plan says there is no evidence of a relationship between the enrollee and the ordering provider.
The Plan must follow Medicare rules. The rules state that the medical record must contain sufficient documentation of the medical condition to substantiate the necessity.
The file shows that a knee brace and suspension sleeve were provided. We looked at the file and the rules. The record does not contain valid proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. The record provided appears to be a phone conversation with the enrollee presenting her problems. The records do not include previous physical exams, testing, or imaging to confirm a diagnosis or condition. There are insufficient medical records to substantiate the items provided. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the orthosis provided March 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81407, 81408, 81439) provided July 15, 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 is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment testing/panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular-respiratory disease. We looked at the file and Medicare rules. Cardiovascular risk assessment testing 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, 81439) provided July 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services from October 15, 2019, through January 27, 2020.

You asked the Plan to waive the copayment for inpatient hospital services. You say that you disagree with the charges. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $360 copayment for each admission for inpatient hospital care for days 1-5 and a $0 copayment for days 6-90 for inpatient hospital care.

The enrollee has been asked to pay a $1800 copayment for inpatient hospital care. The services at issue fall within the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital services from October 15, 2019, through January 27, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve radiofrequency ablation services.
You asked the Plan to pre-approve the requested services. You say that the enrollee is in severe pain. The Plan denied your request. The Plan says that you already had at least 2 ablation session in the last 12 months.
The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation is only covered under certain medical indications. We looked at the file and Medicare rules. The records show that the enrollee received left RFA services on June 10, 2020, and December 16, 2020. Since the enrollee had a session on June 10, 2020, they are allowed one more session before June 10, 2021, which they received in December. This means the enrollee is eligible for another session within the 12 months after December, but not before the 12 months from June expires. Based on this information, we decided that Medicare rules for coverage of the requested services have been met. Therefore, we decided that the Plan has to pre-approve radiofrequency ablation services.
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 waive the copayment for the intraoral complete series, including bitewings (D0210) provided on September 9, 2020.

You asked the Plan to waive the copayment for dental code D0210. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received intraoral complete series, including bitewings with dental code D0210. The Plan says the correct copayment has applied per your contract with the Plan.

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. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received intraoral complete series, including bitewings represented by dental code D0210. The Plan contract clearly says there is a $40 copayment for this service. Therefore, we decided that the Plan does not have to waive the copayment for the intraoral complete series, including bitewings (D0210) provided on September 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle libre 2 sensor kit, for the enrollee.

You asked the Plan to pre-approve Freestyle libre 2 sensor kit. You say that the enrollee has received several education sessions on how to use a blood glucose monitor, without success. You state much of her struggle is the arthritis in their fingers, making it difficult to handle the lancets and test trips. You state the enrollee lives alone and does not have a support person to assist with this either. The Plan denied your request. The Plan says the Medicare rules have not been met.

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 and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin. 

Based on this information, we decided that Medicare rules for coverage of Freestyle libre 2 sensor KIT. have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle libre 2 sensor kit, for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81407 and 81408) provided February 15, 2021.
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 is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for patients with suspected or documented cardiovascular disease. We looked at the file and Medicare rules. The services at issue are 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 and 81408) provided February 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a chemotherapy combination of Keytruda, docetaxel, and cytoxan.
You asked the Plan to pre-approve Keytruda, docetaxel, and cytoxan. You say that this is a newly FDA-approved treatment. The Plan denied your request. The Plan says the denial of authorization for this drug combination is correct, because studies have not proven that these drugs are helpful for the enrollee's condition.
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 Keytruda, docetaxel, and cytoxan. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested chemotherapy combination. Our physician reviewer found this drug combination is not approved by the Food & Drug Administration (FDA) for the enrollee's diagnosis. This combination is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda, docetaxel, and cytoxan have not been met. Therefore, we decided that the Plan does not have to pre-approve a chemotherapy combination of Keytruda, docetaxel, and cytoxan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oximeter device for measuring blood oxygen levels non-invasively (E0445).
You asked the Plan to pre-approve a pulse oximeter. You say that you need this device to help you with your heart condition as you have been to the emergency room many times. The Plan denied your request. The Plan says this item is not a covered item.
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. Based on this information, we decided that Medicare rules for coverage of a pulse oximeter have not been met. Therefore, we decided that the Plan does not have to pre-approve an oximeter device for measuring blood oxygen levels non-invasively (E0445).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chemotherapy administration provided on March 18, 2021.
You asked the Plan to waive the copayment for the chemotherapy administration. You say that the claim should have been billed as 20% coinsurance. You say the cost should be waived because of this error. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $475 copayment for each Medicare-covered outpatient hospital services.
You have been asked to pay a $475 copayment for the chemotherapy administration. The chemotherapy administration falls within the "Outpatient hospital 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 the chemotherapy administration provided on March 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine additional trips.
You asked the Plan to pre-approve additional routine additional trips. You say that you have been diagnosed with pancreatic cancer and need the transportation for much needed surgery and follow up/treatments. The Plan denied your request. The Plan says your request for additional routine transportation is not approved.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at your request, the records in the case file, and the rules. The 25th trip and beyond is not a covered benefit. Your requested exceeds the benefit. Your 2021 EOC states twenty-four (24) one-way trips, combined in and out-of-network, are covered per calendar year (limited to ground transportation only). Therefore, we decided that the Plan does not have to pre-approve additional routine additional trips.
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 this is medically necessary. The Plan denied your request. The Plan says you can be treated at a lower 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 you do not require treatment by multiple therapies and an intensive rehabilitation therapy program. While the documentation does support a need for physical or occupational therapy, there is
no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the 4Kscore testing provided on October 27, 2020.
You asked the Plan to pay for the 4Kscore testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that 4Kscor testing is only covered for certain indications. 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 the 4Kscore testing. Our reviewer says that the documentation does not support that the services rendered were medically reasonable or necessary. Our physician reviewer found the enrollee has elevated prostate-specific antigen (PSA) of 6.95 ng/mL. No other clinical information was provided. The clinical information provided is not sufficient to confirm that all coverage criteria have been met.
Review of the file shows that the Plan uses Local Coverage Determination (LCD) L37013 to support their denial. However, LCD L37013 is not valid for the provider's billing state of New Jersey. Therefore, we are unable to use L37013 to substantiate our decision. 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 4Kscore testing have not been met. Therefore, we decided that the Plan does not have to pay for the 4Kscore testing provided on October 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance charged for Continuous positive airway pressure (CPAP) machine provided from February 18, 2021, to April 18, 2021.

You asked the Plan to waive this coinsurance. You say that you should not have to pay this cost share because the driver did not show you how to use the equipment and you have not used it. The Plan denied your request. The Plan says you accepted delivery of this equipment and this cost share was applied per your Plan contract agreement.

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 20% coinsurance for durable medical equipment.

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 charged for Continuous positive airway pressure (CPAP) machine provided from February 18, 2021, to April 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81479) provided October 15, 2020.
You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. The Plan denied your request. The Plan says this test was ordered for screening purposes and is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal was requested solely 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 genetic testing (81479) provided October 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing - one to three teeth per quadrant (D4342) provided April 27, 2021.
You asked the Plan to pay for the periodontal scaling and root planing. You say that when you enrolled in your dental benefits you were told that periodontal service would be covered in network at 30% and the Plan documentation says that periodontal maintenance and cleanings are covered, four per calendar year. The Plan denied your request. The Plan says you have exceeded frequency limits for this procedure. The periodontal maintenance/cleaning is a different procedure with different frequency limits.
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 periodontal scaling and root planing once per quadrant every three calendar years. We looked at the file and Medicare rules. The Plan provided documentation showing periodontal scaling and root planing was previously covered on May 21, 2019.
The periodontal maintenance benefit you mentioned is a different service than the service at issue. Based on this information, we determined that the Plan's rules frequency limit for the periodontal scaling and root planing have been exceeded. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing - one to three teeth per quadrant (D4342) provided April 27, 2021.