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

We decided that the Plan does not have to pre-approve continued care with Uplizna for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is FDA-approved and has a better safety profile than Rituximab. The Plan denied your request. The Plan says a review of the records confirms no relapse in the last 12 months.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no documentation that the requested drug is medically necessary for the enrollee. The enrollee is stable on Rituximab with no documented relapses. 

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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve continued care with Uplizna for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prednisone.

You asked the Plan to pre-approve Prednisone. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not include Part D prescription coverage. Therefore, coverage criteria has not been met.

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 Prednisone.

Benefits for Prednisone may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adult brief/diapers.

You asked the Plan to pre-approve adult brief/diapers. You say that the items 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. Medicare rules say that incontinence garments (e.g., briefs, diapers) coded A4520 will be denied as statutorily non-covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of adult brief/diapers have not been met. Therefore, we decided that the Plan does not have to pre-approve adult brief/diapers.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture treatments.

You asked the Plan to pre-approve the acupuncture treatments. You say that you need this treatment and feel it should be covered. The Plan denied your request. The Plan says the requested provider is not Medicare-certified.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments when rendered by certain types of providers. 

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the requested provider is not a physician, physician assistant, or nurse practitioner/clinical nurse specialist. There is also no evidence that these services would be provided under the general supervision of one of these provider types. Therefore, we decided that the Plan does not have to pre-approve acupuncture treatments.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the electronic connection between two or more power seating motors (E2311).
You asked the Plan to pre-approve the wheelchair accessory. You say that you would like reconsideration because this accessory is medically necessary. The Plan denied your request. The Plan says the notes do not show a medical need to control the power options through the joystick.
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 wheelchair accessory. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the member does not need to operate 3 or more powered seating actuators through the drive control, a separate display, other electronic devices, or an attendant control. The member's strength and functional ability are sufficient for the member to control any power options through their own individual switches. 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 wheelchair accessory have not been met. Therefore, we decided that the Plan does not have to pre-approve the electronic connection between two or more power seating motors (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider from August 25, 2020, to October 1, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-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 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 had network providers available who could have provided 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 for the medical services provided to you by an out-of-network provider from August 25, 2020, to October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the office visit and the laboratory work provided on September 23, 2020.

You asked the Plan to waive the cost share for the office visit and the laboratory work. You say that the services should be covered as an annual wellness visit. You say you should not have to pay anything. 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 $10 copayment for primary care physician and 10% coinsurance for laboratory tests. 

You have been asked to pay a $10 copayment for the office visit. You have been asked to pay $9.46 which is 10% of the allowed amount for the laboratory work. The allowed amount is $94.62. ($94.62 x 10% = $9.46).

The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows you were seen for a follow-up visit for chronic medical problems.

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 share for the office visit and the laboratory work provided on September 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673, E0650) and a water circulating head pad with a pump (E0249 and E0236) provided on January 14, 2020.
You asked the Plan to pay for pneumatic compression devices and a water circulating head pad with a pump. You say that these items should be covered. The Plan denied your request. The Plan says these items are not covered under Medicare rules.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a water circulating heating pad system is not medically necessary, and a replacement pump (E0236) or pad (E0249, A9999) will be denied as not reasonable and necessary. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. The record shows that these items were ordered for the prevention of venous thromboembolism. This item is used for a preventative service and is excluded from Medicare coverage. The water circulating head pad with a pump is a non-covered item. Therefore, we decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673, E0650) and a water circulating head pad with a pump (E0249 and E0236) provided on January 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee's acute needs have been met and stabilized in the acute care setting and she is stable to transfer to a LTACH for the continuation of care in the long term care setting. The Plan denied your request. The Plan says the enrollee does not meet the requirements for coverage of LTACH care.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that based on the documentation provided, it is my opinion that the health Plan's denial of LTACH coverage should be upheld. The enrollee is currently undergoing treatment at an ACH for status epilepticus and aspiration. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee remains on a ventilator with poor neurologic status. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs. 

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for 10 acupuncture sessions (97811 x 10) from February 21 to October 2, 2020.

You asked the Plan to waive the coinsurance for 10 acupuncture sessions. You say that you should be reimbursed 50% of the billed charges as you were led to believe when you called the Plan. The Plan denied your request. The Plan says the correct cost-sharing was 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 50% coinsurance for each visit for acupuncture therapy. 

You have been asked to pay $13.93, or 50% of the Medicare-allowed amount of $27.85, for each one of 10 acupuncture sessions. The requested services were received from an out of network provider. The Plan contract states that when services are received from an out of network provider, the Plan will pay 50% of the allowance or acupuncturist's charges, whichever is less, and that you are responsible for balances up to the acupuncturist's charge. 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 10 acupuncture sessions (97811 x 10) from February 21 to October 2, 2020.

Your complaint about receiving erroneous or ambiguous information about your cost-sharing responsibility from a representative of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Azilect.

You asked the Plan to pre-approve Azilect. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not include Part D prescription coverage. Therefore, coverage criteria has not been met.

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 Azilect.

Benefits for Azilect 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant supported crown (D6066) provided on September 21, 2020.
You asked the Plan to pay for the implant supported crown. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this service is not covered under your supplemental 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 pay for the implant supported crown (D6066) provided on September 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 26, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 had network providers available who could have provided 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 for the medical services provided to the enrollee by an out-of-network provider on September 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on July 27, 2020.

You asked the Plan to pay for the 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 had network providers available who could have provided 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 for the medical services provided to the enrollee by an out-of-network provider on July 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on June 17, 2020.

You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on July 17, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the monitoring feature/device rendered from August 19, 2020 to October 19, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code A9279 is not separately payable.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. We looked at the file and Medicare rules. Billed procedure code A9279 has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the monitoring feature/device rendered from August 19, 2020 to October 19, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transportation to a hospital other than the nearest appropriate facility.
You asked the Plan to pay for ambulance transport. You say that the Plan wanted to transfer you to a location where you do not live and know no one, but you needed to be at a hospital near your home. The Plan denied your request. The Plan says the denial of payment for this service is correct, because transportation to a facility that is not the closest to your location is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A hospital other than the nearest hospital capable of furnishing appropriate care for a patient's illness or injury is not covered. The services you have asked the Plan to pay for are ambulance transport services to a hospital other than the nearest appropriate facility for your condition. Therefore, we decided that the Plan does not have to pay for ambulance transportation to a hospital other than the nearest appropriate facility.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that continued care is medically necessary. The Plan denied your request. The Plan says the enrollee's needs are custodial.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found at the time of admission, the member required skilled rehab services to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of February 14, 2021, the member did not require any skilled nursing or rehab services on a daily basis. She was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. The member did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care. She did not have any parental medications, complex wound care or nutrition given via a feeding tube. The member received skilled care with minimal improvement, however her function had plateaued by February 13, 2021, and she did not require any further inpatient skilled rehab services. The member's function was at or near her prior level of function and she could be discharged to a lower level of care for further services. As of February 14, 2021, the member required only custodial services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 had network providers available who could have provided 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 for the medical services provided to the enrollee by an out-of-network provider on September 3, 2020.