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

We decided that the Plan does not have to pre-approve twenty-five (25) inpatient or outpatient dialysis treatments for the enrollee, to be performed by an out-of-network provider.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says there are other providers that the Plan does cover that can give the enrollee the same care.
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 twenty-five (25) inpatient or outpatient dialysis treatments for the enrollee, to be performed by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary for the enrollee. 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 follows these 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 pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve clinical crown lengthening (D4249) and a bone replacement graft (D7953).
You asked the Plan to pre-approve the dental services. You say that you feel these services are medically necessary. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's supplemental dental 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-approve clinical crown lengthening (D4249) and a bone replacement graft (D7953).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient therapies provided by a non-participating provider.

You asked the Plan to waive the coinsurance for outpatient therapies. You say that you do not want to pay for this. The Plan denied your request. The Plan says the correct coinsurance has been applied.

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 outpatient rehabilitation services.

You have been asked to pay a 20% coinsurance of the allowed amount for outpatient therapies. The total allowed amount is $317.57. The total amount you are being asked to pay is $63.52 ($317.57 x 20% = $63.52). The correct coinsurance has been applied to the services that were provided. Outpatient therapies fall within the outpatient rehabilitation 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 coinsurance for outpatient therapies provided by a non-participating provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carboplatin, Pemetrexed, and Pembrolizumab.
You asked the Plan to pre-approve Carboplatin, Pemetrexed, and Pembrolizumab. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drugs are not medically necessary.
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 Carboplatin, Pemetrexed, and Pembrolizumab. Our reviewer says that the documentation does not support that the requested drugs are medically reasonable or necessary. Our physician reviewer found the enrollee has stage IV adenocarcinoma of the lung with 80% PDL1 expression. The enrollee received Keytruda (Pembrolizumab) for three cycles and a follow up PET scan demonstrated significant progression (30%) of disease with additional lesions present. The enrollee has demonstrated progression on Keytruda. The Medicare compendia, including National Comprehensive Cancer Network Guidelines, do not support the continued use of Keytruda when first line therapy progresses. The Food and Drug Administration does not support the requested regiment for the enrollee's condition. The Medicare compendia do not support the requested regimen for the enrollee's condition. Therefore, the enrollee does not meet criteria for the requested drugs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Carboplatin, Pemetrexed, and Pembrolizumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Carboplatin, Pemetrexed, and Pembrolizumab.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dialysis services (A4657, G0491, J0882, J2916) provided from October 2, 2020, to October 30, 2020.
You asked the Plan to pay for dialysis services. You say that this was billed correctly. The Plan denied your request. The Plan says this was not billed with a correct principal diagnosis.
The Plan must follow Medicare rules. Medicare rules say that that hospital-based and independent renal facilities must complete the Principal Diagnosis Code claim item and it should include a diagnosis of end stage renal disease. We looked at the file and Medicare rules. The principal diagnosis on this claim is for anemia rather than end stage renal disease. Based on this information, we decided that Medicare rules for coverage of dialysis services have not been met. Therefore, we decided that the Plan does not have to pay for dialysis services (A4657, G0491, J0882, J2916) provided from October 2, 2020, to October 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of an auricular peripheral nerve stimulation
device.
You asked the Plan to pre-approve the requested nerve stimulation device. You say that you would like the
Plan to reconsider their denial. The Plan denied your request. The Plan says these devices are not covered by
Medicare.
The Plan must follow Medicare rules. Medicare rules say that auricular peripheral nerve stimulators are electroacupuncture
devices which are not covered by Medicare. Therefore, we decided that the Plan does not have to
pre-approve placement of an auricular peripheral nerve stimulation device.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on August 6, 2020.
You asked the Plan to waive the copayment for a colonoscopy. You say that you disagree with the charges because you were told that if you waited a year the colonoscopy would be covered. 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 $300 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The medical records show that you had polyps removed during a colonoscopy on August 6, 2020. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $300 copayment. You have been asked to pay a $300 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 a colonoscopy provided on August 6, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orencia injection (J0129).

You asked the Plan to pre-approve Orencia. You say that your body is not taking other medications and that your doctor wants to trial Orencia. The Plan denied your request. The Plan says rules for pre-approval are not met because preferred drugs are not shown to have been trialed.

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 Orencia. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found that the case file does not contain documentation of trial and failure of Inflectra, Remicade, or Simponi Aria. The documentation does not support that Inflectra, Remicade, or Simponi Aria 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 Orencia have not been met. Therefore, we decided that the Plan does not have to pre-approve Orencia injection (J0129).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the seat lift mechanism and chair (E0627, E1399) provided May 24, 2020, by a provider not certified with Medicare.
You asked the Plan to pay for the seat lift mechanism and chair. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this is not a Medicare certified provider.
The Plan must follow Medicare rules. Medicare rules say that payment cannot be made to a provider not certified with Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the seat lift mechanism and chair have not been met. Therefore, we decided that the Plan does not have to pay for the seat lift mechanism and chair (E0627, E1399) provided May 24, 2020, by a provider not certified with Medicare.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L1833, L2397) provided September 11, 2020.
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that these items were medically necessary for the enrollee. The Plan denied your request. The Plan says there was no established relationship between the provider and the member.
The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to the criteria listed 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 pay for the knee orthosis and suspension sleeve. Our reviewer says that the requested items were not medically reasonable and necessary. Our physician reviewer found there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L1833, L2397) provided September 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Fentanyl patch for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under Part B.

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 the Fentanyl patch for the enrollee.

Benefits for this drug 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epogen (J0885).
You asked the Plan to pre-approve Epogen. The Plan denied your request. The Plan says the information does
not indicate the enrollee has tried and failed the preferred step therapy drug, Retacrit, for at least two
consecutive months, with appropriate dose adjustment.
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 Epogen. Our reviewer says that Epogen
(J0885) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan
requires a trial of drug Retacrit before they will approve the requested drug. Our reviewer found that the
enrollee has not tried and failed the required drug. Our physician reviewer also found that there is no
documentation provided indicating that the Plan's required drug would likely 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 Epogen have not been met. Therefore, we decided that the Plan does not have to
pre-approve Epogen (J0885).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup on tooth #31 (D2950).
You asked the Plan to pre-approve core buildup on tooth #31. You say that the service is necessary. The Plan denied your request. The Plan says the requested 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-approve core buildup on tooth #31 (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0648) provided October 13, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the item provided was medically necessary for the enrollee. The Plan denied your request. The Plan says there was no evidence of an established relationship between the member and the ordering physician.
The Plan follows Medicare rules. Medicare rules say that the lumbar-sacral orthosis is subject to the criteria listed 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 pay for the lumbar-sacral orthosis. Our reviewer says that the requested orthosis was not medically necessary and reasonable. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support
that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the back. 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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0648) provided October 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B prescription drug provided on November 2, 2020.
You asked the Plan to waive the coinsurance for a Medicare Part B prescription drug. You say that you disagree with the additional charges. 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B prescription drug on November 2, 2020. The total allowed amount is $394.63 and 20% of that is $78.93. You have been asked to pay the total coinsurance amount of $78.93 for a Medicare Part B prescription drug. A Medicare Part B prescription drug 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 coinsurance for a Medicare Part B prescription drug provided on November 2, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. As you are not receiving skilled nursing or skilled therapy the criteria of home health aide services are not met and the request for home health aide services is not reasonable and necessary to the treatment of your illness or injury by the skilled professional staff. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this item is medically necessary. The Plan denied your request. The Plan says the criteria for therapeutic continuous glucose monitors has 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. We looked at the file and Medicare rules. The documentation indicates that you do not insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the treatment of lumbar spinal stenosis. The Plan denied your request. The Plan says this service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the requested service is not considered medically reasonable and necessary. Our physician reviewer found that the Vertiflex spacer is experimental. More research is needed to show the safety and efficacy of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).