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

We decided that the Plan does not have to pre-approve the Freestyle Libre 14 day sensor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says this cannot be approved at this time.
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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the monitor is considered therapeutic and there is a diagnosis of diabetes mellitus. The enrollee has not been using insulin multiple times (3 or more) a day and treatment does not require frequent adjustment on the basis of testing results. 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre 14 day sensor for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychotherapy services to be provided by the out-of-network provider.
You asked the Plan to pre-approve the psychotherapy services. You say that you worked for 26 years in the Plan's Behavior Health Department as a Clinical Child/ Adolescents Psychotherapist. You say that due to your employment with the Plan and the fact that you are familiar with many of the providers, you would not be comfortable discussing your life stressors in this setting. The Plan denied your request. The Plan says should receive all available covered services from plan providers. In the event, covered services are not available in-plan, the Health Plan will refer the enrollee to a designated community network provider. Except for in the area emergency or out of area emergent/ urgent care, HMOs are not required to pay for any services received by the enrollee that is not provided directly by or arranged through the organization.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve psychotherapy services to be provided by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a battery-operated portable oxygen concentrator.
You asked the Plan to pre-approve these services. You say that the portable tank is more convenient and will help you travel. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The file shows that you have a home oxygen system with home fill tanks. This current equipment serves the same purpose as the requested portable oxygen concentrator. Furthermore, the file shows that you are requesting the services for use outside of the home, which is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a battery-operated portable oxygen concentrator.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to approve continued skilled nursing facility (SNF) services beyond
December 25, 2020.
You asked the Plan to approve these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the continued services are not medically necessary.
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 approve these services. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the records show that you were admitted to the
SNF on December 9, 2020 for skilled therapy. You need varied levels of assistance for sitting, standing, bed
mobility, and transfers. The records do not show that you have complex wound care or other skilled nursing
needs on a daily basis. You do not require skilled therapy on a daily basis. As a practical matter, you do not
require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not
have to approve continued skilled nursing facility (SNF) services beyond December 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on September 12, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe laboratory services. 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 a covered benefit.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 forthe laboratory services provided on September 12, 2020 by an out of network (OON) provide
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea continuous glucose monitor.You asked the Planto pre-approvethe monitor. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee is not performing daily blood glucose monitoring.
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 monitor. Our reviewer says that the requested monitor is not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the monitor is not considered therapeutic. There is no diagnosis of diabetes mellitus.The enrollee has not been using insulin multiple times (3 or more) a day. The treatment does not require frequent adjustment on the basis of testing results.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 monitor have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe gingival irrigation (D4921).You asked the Plan to pre-approvethe gingival irrigation. You say that these services are medically necessary.The Plan denied your request. The Plan says the services requested are not a covered benefit.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.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvethe gingival irrigation (D4921).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair (PWC) (K0861) and
accessories (E2311, E2377, E2313, E2361, E1007, E1028, E0955, E1012, E2601).
You asked the Plan to pre-approve a group 3 PWC and accessories. You say that this is medically necessary.
The Plan denied your request. The Plan says the enrollee does not meet the criteria for this power wheelchair.
The Plan must follow Medicare rules. Medicare rules say that a Group 3 PWC is covered if the beneficiary's
mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity.
We looked at the file and Medicare rules. The submitted medical records do not show that the enrollee's
mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity. Based on
this information, we decided that Medicare rules for coverage of a group 3 PWC and accessories have not been
met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair (PWC)
(K0861) and accessories (E2311, E2377, E2313, E2361, E1007, E1028, E0955, E1012, E2601).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia.You asked the Plan to pre-approveProlia. You say that the requested Prolia is medically necessary.The Plan denied your request. The Plan says the enrollee must try and fail Bisphosphonate therapy after 24 months of use.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 Prolia. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is with osteoporosis. The plan's step therapy criteria require documentation of trial and failure with bisphosphonate therapy after 24 months of use.  The documentation indicates that the enrollee has been treated with Fosamax from 2016 -2020, and that bone mineral density T-score has improved inboth the lumbar spine and the hips since the enrollee has been treated with Fosamax.  There is insufficient documentation that the plan's step therapy criteria have been met, or that an exception to the plan's step therapy criteria is 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 Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvethese services. You say that the orthotics will assist you with less pain when walking.The Plan denied your request. The Plan says the services are not covered.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 follows these same rules.  Records show that youdo not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6549.You asked the Plan to pre-approvethe compression stockings. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says gradient compression stockings with CPT code A6549 are not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6549.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Gelsyn.

You asked the Plan to pre-approve Gelsyn. You say that the enrollee had previously tried Genvisc.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the enrollee has not tried and failed the Plan's preferred drugs.

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 Gelsyn. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Gelsyn. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drugs of Euflexxa, Synvisc, or Synvisc-One. Based on the records provided there is no indication that the Plan's preferred drugs would likely beless effective and/or 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 Gelsyn have not been met.Therefore, we decided that the Plan does not have to pre-approve use of Gelsyn.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay foran office visit received on June 5, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe services received 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 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 Plandoes not haveto pay foran office visit received on June 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the automatic external defibrillator, with
integrated electrocardiogram analysis, garment type (K0606) provided July 16, 2020.
You asked the Plan to waive the copayment for the automatic external defibrillator. You say that you feel that
this should be covered in network at 20% because the vest in only made by one company. The Plan denied your
request. The Plan says this claim was processed and the correct coinsurance applied per the plan benefits.
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 30%
coinsurance for each out of network Medicare covered durable medical equipment item.
You have been asked to pay $877.68 for the automatic external defibrillator. The automatic external
defibrillator falls within the Durable medical equipment (DME) and related supplies 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 automatic external defibrillator, with integrated
electrocardiogram analysis, garment type (K0606) provided July 16, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for a wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories (A6650-KX-NU) provided December 18, 2019, to December 20, 2019.
You asked the Plan to pay for a wound care set. You say that the services are supported by the medical records. The Plan denied your request. The Plan says that the modifiers billed are not valid.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Suppliers must add a KX modifier to a code only if all of the criteria in the "Coverage Indications, Limitations and/or Medical Necessity" section of the related LCD have been met. We find that CPT code A6650-KX-NU is supported in the medical record. Specifically, the modifiers billed appear appropriate for the supplies provided. The Plan has not provided specific rationale to show why the billed modifiers are not appropriate. Based on this information, we decided that Medicare rules for coverage of a wound care set have been met. Therefore, we decided that the Plan has to pay for a wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories (A6650-KX-NU) provided December 18, 2019, to December 20, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that you would like to stay at your current rehab center to avoid being exposed to COVID-19. You also say that you think it is reasonable to stay at this rehab and wait until you can get the COVID-19 vaccine.The Plan denied your request. The Plan says you are medically stable, and no longer require the intensity of services provided at an acute inpatient rehabilitation 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 above.Weasked 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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitationcare. Our reviewer found that you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. Our physician reviewer also found that 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 haveto pre-approveacute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (82542, 84228, G0483) provided.

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 the services were not emergent or pre-authorized. There were network providers available.

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 service 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 lab services (82542, 84228, G0483) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe core buildup (D2950).You asked the Plan to pre-approvethe core buildup. You say that the service is medically necessary.The Plan denied your request. The Plan says this service is not a covered benefit.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.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvethe core buildup (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea partial upper denture (D5213) and a partial lower denture (D5214).You asked the Plan to pre-approvethe dental items. You say that you are missing most of your molars. You say that you cannot eat properly as a result. You also say that this effects your health.The Plan denied your request. The Plan says partial dentures are not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The Evidence of Coverage specifically states that prosthodontic treatment including, but not limited to bridges, implants, dentures, partial dentures, or the oral surgical preparation for pre-prosthetic proceduresare excluded from coverage.Therefore, we decided that the Plan does not have to pre-approvea partial upper denture (D5213) and a partial lower denture (D5214)