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

We decided that the Plandoes not haveto pre-approvethe Gel-One injection.You asked the Planto pre-approvethe injection. You say that this is medically necessary, as you can barely walk.The Plandenied your request. The Plansaysstep therapy policy has not been met.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 the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found there is no evidence of a trial and failure of Euflexxa or Synvisc-One. The documentation does not support that Euflexxa and Synvisc-One would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.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 injection have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe Gel-One injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Sleep Number smart bed (E1399).You asked the Plan to pre-approvea Sleep Number smart bed. You say that the enrollee received a Sleep Number in the past that improved his problems.The Plan denied your request. The Plan says this item is not primarily medical in nature.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvea Sleep Number smart bed (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve trastuzumab injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy guidelines were not followed.
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 the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found in this case, the enrollee has not tried and failed the required step therapy drugs. There is no documentation that the plan's required drug(s) is likely to be 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 the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve trastuzumab injection for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a colonoscopy and laboratory services and does not have to waive the coinsurance for Medicare Part B drugs provided on July 25, 2019.You asked the Plan to waive the copayments fora colonoscopy and laboratory services and to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the charges due to a positive Cologuard test.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $250 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. Your contract with the Plan also clearly says that you must pay a $10 copayment for laboratory tests. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. The medical records show that you had a positive Cologuard test. Therefore, the colonoscopy on July 25, 2019 is considered diagnostic, not preventative, and you are responsible to pay your share of the cost-sharing charges. Please see the chart below. The total amount you owe is: $279.02.You have been asked to pay the total amount of $279.02 for a colonoscopy, laboratory services and Medicare Part B drugs. A colonoscopy falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. Medicare Part B drugs 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 copayments fora colonoscopy and laboratory services and does not have to waive the coinsurance for Medicare Part B drugs provided on July 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe mammogram provided on October 23, 2019.You asked the Plan to waive the copayment forthe mammogram. You say that this was a screening. You say that you should have no copayment.The Plan denied your request. The Plan says the copayment 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 $40 copayment for Medicare-covered x-rays and ultrasounds.You have been asked to pay a $40 copayment for the diagnostic mammogram.The mammogram falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the mammogram was ordered due to asymmetry in the left breast, which is considered diagnostic. 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 forthemammogram provided on October 23, 2019.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve proton beam therapy for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says that the request does not meet the plan's coverage criteria.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the therapy. Our reviewer says that the requested therapy is considered medically reasonable and necessary in this case. Our physician reviewer found the plan does not show beam arrangements, but it appears that a VMAT (using arcing beams) or multi-angle IMRT approach for the IMRT was used -instead of tangential beams - which can increase the exposure of the heart and lungs. The use of proton therapy is an accepted radiation technology, that has proven efficacy and tolerability. Certain conditions- such as base of skull chordomas and chondrosarcomas, and pediatric CNS malignancies are probably best treated with proton therapy, due to the sharp dose fall off, allowing high dose delivery to the tumor, while relatively sparing the neighboring normal tissue. Whether or not proton therapy (in general) affords any benefit over conventional radiation therapy is a heated issue, with quite disparate opinions among experts in the field. Thus, case reviews for proton therapy for breast cancer are challenging since proton therapy will invariably reduce heart and lung exposure- but not always in a clinically meaningful way, and an IMRT plan can often be made to look better or worse depending on beam arrangement, planning parameters, etc. Nevertheless, it is apparent that the proton plan is markedly better with respect to heart and lung exposure, this difference allows for the heart and lung constraints of a national study (reflecting national standards) to be readily met, and therefore this difference is likely clinically meaningful. 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 therapy have been met. Therefore, we decided that the Plan has to pre-approve proton beam therapy for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 10, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says he Plan
requires utilization of network providers when possible and available, and requires authorization for certain
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 did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for laboratory services provided on September 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on December 4, 2018.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the only information submitted was the drug test.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on December 4, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiogram provided on September 20, 2019.You asked the Plan to waive the copayment forthe echocardiogram. You say that you were seen in a clinic and not a hospital. You say you should not be charged a $95 copayment. The Plan denied your request. The Plan says you have been charged 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 $95 copayment for basic radiology services at an in-network outpatient hospital. You have been asked to pay a $95 copayment for the echocardiogram. The echocardiogram falls within the "Outpatient hospital services" benefit category. The record shows you were billed by an outpatient hospital.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 echocardiogram provided on September 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis provided on May 28, 2019.You asked the Plan to pay forthe shoulder elbow wrist hand orthosis (L3960). You say that the shoulder orthosis was medically necessary.The Plan denied yourrequest. The Plan says the records do not support the need for the orthosis.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. The most recent progress notes do not address shoulder pain or need for the orthosis. Based on this information, we decided that Medicare rules for coverage of the shoulder orthosis (L3960) have not been met.Therefore, we decided that the Plan does not have to pay forthe shoulder elbow wrist hand orthosis provided on May 28, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from April 1, 2018 to May 1, 2018.You asked the Plan to pay forthe skilled nursing services. You say that you have called customer service multiple times over the last year and each time they said they would send the appeal back for review. You also say that you still have not received a decision for these dates of service.The Plan denied your request. The Plan says the enrollee did not require daily skilled therapy services after March 25, 2018 and was only receiving intermittent skilled therapy services after. The Plan also says that the enrollee was custodial and in long-term care setting.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 casefile and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, andjudgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.We looked at this physician's review, the file, and Medicare rules. Based on this information,we decided that Medicare rules for coverage of the skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from April 1, 2018 to May 1, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on to the enrollee by an out-of-network provider on May 20, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on to the enrollee by an out-of-network provider on May 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran annual wellness exam provided on August 22, 2019 by an out of network (OON) provider.You asked the Plan to pay foran annual wellness exam. You say that these services were medically necessary.The Plan denied your request. The Plan says 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 foran annual wellness exam provided on August 22, 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 acupuncture.You asked the Plan to pre-approve acupuncture. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not a covered benefit.The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.The services at issue in this appeal are acupuncture services.Therefore, we decided that the Plan does not have to pre-approve acupuncture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical boot (L3260).You asked the Plan to pay forthe surgical boot. You say that you are not a part of the hospital and is unable to obtain pre-authorization at the time of service. Additionally you are a DME supplier and is separate from the hospital.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan followsthese same rules.  Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition.Therefore, we decided that the Plan does not have to pay forthe surgical boot (L3260)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvegenetic laboratory testing.You asked the Planto pre-approvethe testing. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no personal history of malignancy.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the testing. Our reviewer says that the requested testing is not considered medically reasonable and necessary in this case. Our physician reviewer found the laboratory requisition indicates that you have no history of cancer. As such, the documentation does notsupport that the requested testing is medically necessary or reasonable to diagnose, treat or otherwise manage your health.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 testing have not been met.Therefore, we decided that the Plandoes not haveto pre-approvegenetic laboratory testing
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on September 6, 2019.
You asked the Plan to pay for the orthosis. The Plan denied your request. The Plan says that there is no documentation to support that the ordering provider is participating in a Federal telemedicine demonstration project that would exempt them from originating site requirements.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on September 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on September 5, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. 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 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 vision services provided on September 5, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wireless capsule endoscopy.
You asked the Plan to pre-approve the endoscopy. You say that this is medically necessary. The Plan denied
your request. The Plan says this test is used when other tests have not given a clear result.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the endoscopy. Our reviewer says that
the requested endoscopy is not considered medically reasonable and necessary in this case. Our physician
reviewer found the community-accepted indications for capsule endoscopy includes: obscure gastrointestinal
bleeding, small bowel Crohn's disease, assessment of celiac disease, screening and surveillance for polyps in
familial polyposis syndromes, and in evaluation of the small bowel for tumors such as lymphoma, carcinomas
or carcinoids. The medical record supports that the enrollee meets none of these indications.
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 endoscopy have not been met. Therefore, we decided that the Plan does not
have to pre-approve a wireless capsule endoscopy.