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

We decided that the Plandoes not have to pre-approve the Freestyle Libre 14 day sensor.You asked the Planto pre-approvethe sensor. You say that this is medically necesasry.The Plandenied your request. The Plansaysthis is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.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 sensor. Our reviewer says that the requested sensor is not medically reasonable or necessary. Our physician reviewer found no provider records, medication lists or blood glucose logs have been submitted for review. Therefore, thereis no evidence that the enrollee is an insulin-using diabetic, who performs blood glucose testing multiple times a day, and who uses the results of that testing to adjust and administer insulin multiple times a day. Therefore, the requested CGM is not shown to be medically necessary or reasonable.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 sensor have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe Freestyle Libre 14 day sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on February 5, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you sent your bill in for review. 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 $45 copayment for each specialist visit for Medicare-covered benefits. You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 specialist office visit provided on February 5, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to per-approve additional routine transportation for the enrollee.You asked the Plan to per-approve additional routine transportation. You say that the enrollee will require additional transportation assistance.The Plan denied your request. The Plan says once this benefit is exhausted it cannot be extended.Medicare does not cover routine transportation. The Plan covers 24 one-way trips per year. Once this supplemental benefit is exhausted it cannot be extended.  Medicare does not make exceptions for supplemental benefits. Therefore, we decided that the Plan does not have to per-approve additional routine transportation for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided thatthe Plan has to waive the copayment for comprehensive eye exam and refraction services provided October 8, 2019.You asked the Plan to waive the copayment forthe vision services. You say that you were charged for an annual eye exam. You went foryour routine exam and nothing moreThe Plan denied your request. The Plan says that the claim was auto-forward as the appeal was not decided within the required time limit.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay $0 copayment for routine eye exam. Refraction is included for Vision care. The plan has not provided any supportive information that this service was not a routine eye exam.The Plan says you must pay $35 copayment for the vision services. Based on the Plan contract, however, you cannot be asked to pay more than $0 copayment for routine eye exam. Refraction is included for the vision services.Therefore, we decided that the Plan has to waive the copayment forcomprehensive eye exam and refraction services provided October 8, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically reasonable and necessary. The Plan denied your request. The Plan says the enrollee must either have a history of osteoporotic fracture, or failure or contraindication to zoledronic acid first.
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 has a diagnosis of age-related osteoporosis without current pathological fracture. The enrollee does not have a history of osteoporotic fracture. The Plan requires a trial of drug Zoledronic Acid first before they will approve the requested drug, Prolia. The enrollee has not tried and failed Zoledronic Acid. The provider does not state that Zoledronic acid 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous passive motion (CPM) device for the enrollee for shoulder treatment.
You asked the Plan to pre-approve a continuous passive motion (CPM) device for shoulder treatment.. You say that this device is medically necessary. The Plan denied your request. The Plan says this device is only covered by Medicare for treatment of the knee.
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery. The enrollee has not had total knee replacement surgery. The device is being requested for treatment of the shoulder. Therefore, we decided that the Plan does not have to pre-approve a continuous passive motion (CPM) device for the enrollee for shoulder treatment.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approveinsertion of a hypoglossal nerve stimulator.You asked the Plan to pre-approveinsertion of a hypoglossal nerve stimulator. You say that this is medically necessary.The Plan denied your request. The Plan says that this is experimental.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 thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve insertion of a hypoglossal nerve stimulator. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee meets FDA criteria for the device. There are several studies that have looked at hypoglossal nerve stimulation as a way to improve upper airway stimulation and thereby treat obstructive sleepapnea. Based on this high-quality evidence published across different specialties, the hypoglossal nerve stimulator device should not be considered investigational or experimental. In addition, there is long-term data that shows a reduction in the severity of obstructive sleep apnea, good patient compliance, a reduction in sleepiness, and improvement in quality of life.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of a hypoglossal nerve stimulator have been met.Therefore, we decided that the Plan has to pre-approveinsertion of a hypoglossal nerve stimulator.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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission and services for the enrollee.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does not require skilled nursing care.
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 services. Our physician reviewer found that from a nursing perspective, the enrollee has stable vital signs, and his lungs were clear. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at a standby assist to minimal assist level for function mobility. The enrollee required setup with most activities of daily living. Although there are identifiable skilled therapy service needs, the enrollee does not require skilled nursing or therapy services on a daily basis. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for domiciliary or rest home visit provided on August 14, 2019.You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 providersonly 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 servicesat 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 domiciliary or rest home visit provided on August 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forfoot orthotics provided on November 7, 2019.You asked the Plan to pay forfoot orthotics. You say that the Evidence of Coverage does not say who can provide an orthotic.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.  The record does notshow that you suffer fromdiabetic foot disease oryou wear a leg brace. Orthotics must be prescribed by a podiatrist, orthoptist, prosthetist,or pedorthist.The Plan only pays for chiropractic manual manipulation. Therefore, we decided that the Plan does not have to pay forfoot orthotics provided on November 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on November 6, 2019.
You asked the Plan to waive the copayment for the x-ray. You say that you were told any service done during an office visit would be covered under the physician copayment and you would not be billed for anything else, including x-rays. 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 radiological services at an in-network outpatient hospital. You have been asked to pay a $95 copayment for the x-ray. The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you were billed by the 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 x-ray provided on November 6, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSNF admission and services for the enrollee.You asked the Plan to pre-approveSNF services. The Plan denied your request. The Plan says the enrollee's condition does not require skilled nursing care as an inpatient.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 services. Our physician reviewer found that from a nursing perspective, the enrollee has stable vital signs, and was treated for diuresis. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at contact guard assist for functional mobility. Although there are identifiable skilled therapy service needs, the enrollee does not require skilled nursing or therapy services on a daily basis.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 services have not been met. Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) admission and services for the enrollee.
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 July 17, 2019.You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.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 a valid physician order or lab requisition stating exactly which testing was to 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 July 17, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecataract surgery to be provided while out of area (OOA).You asked the Plan to pre-approvethe OOA cataract surgery. You say that you believe that you should be allowed to have this performed in Florida as you feel that it is dangerous for you to continue without treatment of your vision issue.The Plan denied your request. The Plan says this is not a medically urgent issue and can be reasonably delayed until you return to the service area.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.  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 OOA cataract surgery. Our reviewer says that the documentation does not support that the requested OOA cataract surgery is urgently needed. Our physician reviewer found the enrollee is a 52-year-old woman with a diagnosis of Cataract in diseases classified elsewhere. The medical record documents a right cortical cataract through central vision. Her aided visual acuity is recorded as 20/20. The enrollee does not have a medical condition which requires urgent or emergent care. It would be medically reasonable to delay cataract surgery services until the enrollee returns to her service area in early May.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 OOA cataract surgery have not been met.Therefore, we decided that the Plan does not have to pre-approvecataract surgery to be provided while out of area (OOA).
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approve the injections. We decided that the Plan does not have to pre-approve. You asked the Plan to pre-approve the injections. The Plan says that the injections are not medically necessary.We decided that the Plan has to pre-approve the injections at the L4-5 and L5-S1 levels. 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 injections. Our reviewer says that the injections at L4-5 and L5-S1 levels are considered medically reasonable and necessary in this case. Our physician reviewer found that a recent MRI revealed a large broad-based disc bulge at the L4-5 level that flattens the thecal sac and markedly narrows the neural foramina. At L5-S1, a disc bulge narrows the bilateral neural foramina with moderate disc space narrowing. In the progress note dated January 2, 2020, it is documented that the enrollee was offered transforaminal epidural steroid injections at the L4-5, L5-S1 levels on the right side.The documentation in the case file supports epidural steroid injections at the L4-5 and L5-S1 levels, but not at the L3-4 level. Therefore, we decided that the Plan has to pre-approve the injections at L4-5 and L5-S1 levels. We also decided that the Plan does not have to pre-approve the injection at the L3-4 level.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 injections. Our reviewer says that the injection at L3-4 level is considered not medically reasonable and necessary in this case. The documentation in the case file supports epidural steroid injections at the L4-5 and L5-S1 levels, but not at the L3-4 level. Therefore, we decided that the Plan has to pre-approve the injections.  Therefore, we decided that the Plan does not have to pre-approve the injection at the L3-4 level.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: Supplemental Benefit
Decision: Unfavorable

The rules say that plans must pay for a medical service or item ifregular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacementof teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plancovers items and services in accordance with Medicare rules. The Plan contract provides a list of covered services when rendered by a participating provider. The contract also says that the services must be performed by a participating general dentist. You can find this information on pages 63 to 64 of the Plan's 2020 Evidence of Coverage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).You asked the Plan to pre-approve the dental service. You say that you are unable to eat without an upper denture. You say that you have diabetes. You also say that you received an upper denture in 2017 but have since misplaced it and are on a fixed income.The Plan denied your request. The Plan says the frequency limit of once every 5 years has been reached.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 and dentures are a covered service, the frequency limit has been reached. The record shows that you previously received an upper denture on November 7, 2017.Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto for the enrollee.You asked the Plan to pre-approvethis drug. You say that the enrollee needs this for heart failure.The Plan denied your request. The Plan says that this medication 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-approveEntresto for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe genetic testing rendered on September 6, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan saysthe services are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe genetic testing rendered on September 6, 2019