Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuing inpatient mental health services.
You asked the Plan to pre-approve the inpatient mental health services. You say that inpatient level care is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health services. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The patient was compliant with treatment while not showing any acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower 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 the inpatient mental health services have not been met. Therefore, we decided that the Plan does not have to pre-approve continuing inpatient mental health services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the services rendered to you on November
11, 2019 to February 6, 2020.
You asked the Plan to waive the cost sharing for these services. You say that you disagree with the charges.
The Plan denied your request. The Plan says the cost sharing 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 $150
copayment for diagnostic and nuclear medicine radiological services other than mammogram and ultrasounds
and a 20% coinsurance for Medicare-covered Part B drugs.
Review of the file shows that you received an epidurography on November 11, 2019; November 29, 2019; and
February 6, 2020. Per your contract with the Plan, there is a $150 copayment for diagnostic and nuclear
medicine radiological services other than mammogram and ultrasounds. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these
services was $61.33 on November 11, 2019 and November 29, 2019 and $122.65 on February 6, 2020. Given
that the allowed amounts were less than the $150 copayment, you have been asked to pay $61.33 per date of
service for the services on November 11, 2019 and November 29, 2019 and $122.65 for the services on
February 6, 2020.
The file shows that you received Part B drugs on November 11, 2019; November 29, 2019; and February 6,
2020. You have been asked to pay a 20% coinsurance for these services, for a total of $7.17 (or $2.39 per date
of service). These services fall within the in-network Medicare Part B covered drugs benefit category. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. This means you have been
asked to pay the correct amount based on your contract with the Plan/
Therefore, we decided that the Plan does not have to waive the cost sharing for the services rendered to you on
November 11, 2019 to February 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fora CYP gene panel received on October 14, 2019.You asked the Plan to pay for the testing. You say that this should be paid for.The Plan denied your request. The Plan says the coding is not supported in this case.The Plan must follow Medicare rules. Medicare rules say that CYP gene panels need to be coded with CPT 81479, and they are not covered. The denial here is two-fold -the services were not coded correctly, and they are not covered in the first place. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plan does not have to pay fora CYP gene panel received on October 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for breast prosthesis (L8000 and L8035) provided on August 23, 2019.You asked the Plan to pay for the breast prosthesis. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the submitted medical records do not include itemized shipping/billing invoice to indicate the specific supplies were delivered to the patient on the billed date of service The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case.Therefore, we decided that the Plan does not have to pay for breast prosthesis (L8000 and L8035) provided on August 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy services rendered to you on September 20, 2019.
You asked the Plan to waive the coinsurance for these services. You say that the coinsurance is a financial hardship. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each Medicare-covered Part B drug.
Review of the file shows that you received chemotherapy on September 20, 2019. You have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare-covered Part B drug 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 chemotherapy services rendered to you on September 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Etoposide, Cisplatin, Dexamethasone Sodium Phosphate and Aprepitant.
You asked the Plan to pre-approve the drugs. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says original Medicare is responsible for coverage for the routine costs associated with clinical trials.
The Plan must follow Medicare rules. Medicare rules say that routine costs of a clinical trial include all items and services that are otherwise generally available to Medicare beneficiaries. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drugs have not been met. Specifically, during a clinical trial, payment for routine care should be sent to the original Medicare Administrative Contractor. Therefore, we decided that the Plan does not have to pre-approve Etoposide, Cisplatin, Dexamethasone Sodium Phosphate and Aprepitant.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the injections you received on April 4,
2019 to October 8, 2019.
You asked the Plan to waive the cost shares for the services provided. You say that you received services
previously with no charge. The Plan denied your request. The Plan says the cost shares were applied based on
your plan benefits.
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan
contract says that enrollees must pay a 20% coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a 20% coinsurance for the services provided. The services fall within the Medicare
Part B prescription drugs 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 cost shares for the
injections you received on April 4, 2019 to October 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Ipratropium - Albuterol.
You asked the Plan to pre-approve a tier exception for Ipratropium - Albuterol. You say that the enrollee has been using this medication for a year. You also say that the enrollee lives on a fixed income. The Plan denied your request. The Plan says the drug you requested is covered under the enrollee's Medicare Part B (Medical) benefit. The Plan also says that a tier exception cannot be granted for this Part B medication.
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. We looked at the file and Medicare Rules. Based on this information we decided that Medicare rules for a tier exception have not been met. Specifically, the drug at issue is being covered by the Plan under Medicare Part B. Part B Drugs are not eligible for tier exceptions. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Ipratropium - Albuterol.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Amitriptyline HCL 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 this drug is intended for patient self-administration.
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 Amitriptyline HCL for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips beyond the 24 trips allowed per calendar year.
You asked the Plan to pre-approve the additional routine transportation trips. You say that you need coverage for additional trips in order to get to your weekly dialysis treatments. The Plan denied your request. The Plan says the supplemental benefit for routine transportation only allows 24 trip per calendar year, and this benefit has been exhausted for 2020.
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. The Plan covers a maximum of 24 one-way routine transportation trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that more than the allowed 24 one-way routine transportation trips would exhaust the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips beyond the 24 trips allowed per calendar year.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 12, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
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 a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 12, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve routine transportation services.
You asked the Plan to pre-approve routine transportation. You say that you need more trips to go to and from your appointments and have a fear of catching coronavirus by using public transportation. The Plan denied your request. The Plan says that the denial of authorization for these services is correct, because the Plan only covers up to 50 one-way trips for routine transportation and you have exhausted this benefit.
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 submit documentation from the applicable Evidence of Coverage (EOC) showing that your routine transportation benefits are limited to 50 one-way trips for the year of 2020. Without this information, we cannot determine that you have exhausted your supplemental routine transportation benefits at this time. Therefore, the Plan has not shown that its denial of authorization for these services is correct or justified by the Plan contract. Therefore, we decided that the Plan has to pre-approve routine transportation 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the charges for the fulvestrant infusion provided on December 30, 2019.
You asked the Plan to waive the charges for the fulvestrant infusion. You say that you are asking for this to be waived or reduced due to the cost being unaffordable. The Plan denied your request. The Plan says this charge is correctly applied to the Part B drug treatment which has a 20% coinsurance on the cost of the drug and administration. This cannot be waived.
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 Medicare Part B Prescription Drugs. You have been asked to pay 20% coinsurance for the fulvestrant infusion. The fulvestrant infusion falls within the Medicare Part B Prescription Drugs 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 charges for the fulvestrant infusion provided on December 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on November 27, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on November 27, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Brovanna
You asked the Plan to pre-approve Brovanna (J7605). You say that you want the enrollee to use this drug. The Plan denied your request. The Plan says that documentation does not support the medical necessity for a step therapy exception.
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 Brovanna (J7605). Our reviewer says that this drug is medically necessary. Our physician reviewer found the enrollee has demonstrated some intolerance to albuterol. The enrollee has several chronic conditions and this is a reasonable choice to try to minimize side effects in a chronically ill patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Brovanna (J7605) have been met. Therefore, we decided that the Plan has to pre-approve Brovanna
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.
You asked the Plan to pre-approve the additional physical therapy. You say that the member has made significant progress and the skilled services are required to continue progression towards the highest level of function. The Plan denied your request. The Plan says the member's condition has not significantly improved and detail is lacking in skills that require further treatment by a physical therapist.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional physical therapy is not medically reasonable and 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 the additional physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for eye surgery at 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 members can only use doctors who are part of the 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 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 for eye surgery at an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower limb prosthesis accessories (L5962, L5704, L5620, L5629).
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says these items are not covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The requested accessory codes are specifically not covered by Medicare, and not considered medically reasonable or necessary. Based on this information, we decided that Medicare rules for coverage of the accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a lower limb prosthesis accessories (L5962, L5704, L5620, L5629).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Norco Tablets.
You asked the Plan to pre-approve the Norco Tablets. You say that you would like reconsideration to decrease Norco 10-325mg to Norco 7.5-325 to better control the member's pain. The Plan denied your request. The Plan says this medication does not fall under the member's Medicare Part B 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 Norco Tablets.
Benefits for the Norco Tablets 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: 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, as therapy is needed to walk, talk, and use the extremities. The Plan denied your request. The Plan says there is a lack of skilled medical or therapy needs.
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. 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).