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

We decided that the Plan does not have to pre-approve a semi-electric hospital twin long bed.
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says there is no congestive heart failure, chronic pulmonary disease or problems with aspiration that would require elevation of the head of the bed.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 bed. Our reviewer says that the requested bed is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no documentation that your condition requires position of the body in ways not feasible in an ordinary bed. There is no documentation of a need for frequent changes in body position, or immediate changes in body position. There is no requirement for special attachments that cannot be fixed and used on an ordinary bed. 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 bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital twin long bed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services rendered on August 10, 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 the claim was billed incorrectly.
The rules say that all charges, except for therapies, telehealth originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance services are combined and reported under revenue code 0510 (clinic visit) on TOB 13X (hospital outpatient). You can find this rule in the Medicare Claims Processing Manual, Chapter 19, Section 100.5.1. The Plan must follow Medicare rules. Medicare rules say that outpatient hospital services must be reported under revenue code 0510 and TOB 13x. Therefore, we decided that the Plan does not have to pay for the outpatient services rendered on August 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered for treatment of the legs alone.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not have lymphedema of the chest, trunk, or abdomen on an objective physical exam. The enrollee does not have have unique characteristics that would indicate the segmented pump over a standard pump or trial and failure of a standard pump. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve myocardial perfusion imaging (SPECT) for the enrollee.
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee did not meet the Medicare criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that myocardial perfusion imaging is covered under certain conditions. 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 imaging. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found based on the records, the enrollee has increased coronary risk, symptoms of exertional dyspnea concerning for a coronary ischemic equivalent and very poor functional capacity precluding adequate exercise to complete an exercise stress test. In this circumstance, some imaging pharmacologic stress test (dobutamine echo or regadenoson nuclear stress test) is reasonable and appropriate. Current guidelines endorsed by several national organizations also consider nuclear stress testing appropriate in this setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the imaging have been met. Therefore, we decided that the Plan has to pre-approve myocardial perfusion imaging (SPECT) for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Iluvien for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no evidence of advanced glaucoma.
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 treatment is medically reasonable or necessary. Our physician reviewer found treatment with Iluvien in this case is medically necessary and meets coverage criteria based on the medical records and the available medical evidence. In this case, the enrollee is treated for refractory diabetic macular edema that has persisted in spite of other intravitreal treatments (aflibercept ozurdex). Iluvien carries a contraindication in patients with high cup/disc ratio (more than 0.8) because it is an indicator for glaucoma, and intravitreal steroids can cause elevation of intraocular pressure in some cases. Study protocols for intravitreal flucinolone excluded patients with cup/disc more than 0.8 because it is a potential indicator for poorly controlled or severe glaucoma. The labeled contraindication is a reflection of that. The health plan's argument that prior steroid treatment is required before use of Iluvien, however, is not valid. In spite of the FDA labeled contraindication for cupping, there is no medical reason to withhold this drug from a patient with no history of poorly controlled glaucoma. 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 been met. Therefore, we decided that the Plan has to pre-approve Iluvien for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye examination provided on July 13, 2020.
You asked the Plan to waive the copayment for eye exam. You say that you thought this was a free routine eye exam, so you should not be charged a copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 copayment for in-network diagnostic eye exam. This visit address non-routine diagnoses and included diagnostic testing, so it is not considered to be a routine eye exam. Although this visit is considered to be a diagnostic eye exam, the Plan has only applied the $45 copayment for a specialist office visit. You have been asked to pay $45, which is less than the $50 copayment for eye exam. Eye exam falls within the Vision Care 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 an eye examination provided on July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the denosumab injection provided on June 9, 2020.
You asked the Plan to waive the coinsurance for the denosumab injection. You say that the injection was pre-authorized so you should not have coinsurance. The Plan denied your request. The Plan says the coinsurance applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of the cost for Medicare Part B chemotherapy drugs and other Medicare Part B drugs. You have been asked to pay $805.84, which is 20% of the allowed amount for the denosumab injection. The allowed amount is $4,029.20 (20% x $4,029.20 = $805.84). The denosumab injection 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 the denosumab injection provided on June 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided by an out of network provider.

You asked the Plan to pay for the physician services. You say that you were not aware of the enrollee's insurance with the Plan. The Plan denied your request. The Plan says you did not request prior authorization.

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 service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the physician services provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that these items are necessary. The Plan denied your request. The Plan says this service is not covered by Medicare or the Plan.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient lung biopsy (77012, 32405, 71045, 71045).

You asked the Plan to pay for the outpatient procedure. You say that the services were medically necessary. The Plan denied your request. The Plan says 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 had network providers available who could have provided 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 for an outpatient lung biopsy (77012, 32405, 71045, 71045).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services provided on August 3, 2020 and a CT scan, body scan and pharmaceuticals provided on August 13, 2020.
You asked the Plan to pay for the ophthalmological services, CT scan, body scan and pharmaceuticals. The Plan denied your request. The Plan says the enrollee's Plan requires members to see in-network providers only unless preauthorization is approved by the health plan, the services provided are emergent in nature or there are no in-network providers available to provide the services rendered. There was no preauthorization submitted to the health plan, the services rendered were not emergent in nature and there were in-network providers available that could have provided the services rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for ophthalmological services provided on August 3, 2020 and a CT scan, body scan and pharmaceuticals provided on August 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve carvedilol 25mg tablets.
You asked the Plan to pre-approve the carvedilol tablets. You say that the enrollee needs this to control his hypertension. The Plan denied your request. The Plan says this is an oral drug that cannot be covered by Medicare 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 carvedilol 25mg tablets.
Benefits for the carvedilol tablets 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for the chiropractic visit. You say that the enrollee has seen this provider in the past and wants to continue to see him. The Plan denied your request. The Plan says the provider is out of network and the requested service is available with an in-network provider.

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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a routine eye examination (refraction) provided on January 23, 2020.
You asked the Plan to pay for eye exam. You say that you have seen this provider before and feel you should not be paying any additional copayments for this service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this routine eye exam is not covered when performed by an out-of-network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when performed by a Plan preferred routine vision provider. We looked at the file and the Plan's rules. This service was not performed by a Plan preferred routine vision provider. Based on this information, we decided that the Plan's rules for coverage of eye exam have not been met. Therefore, we decided that the Plan does not have to pay for a routine eye examination (refraction) provided on January 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cologuard testing.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that Cologuard testing is covered when specific criteria are met. We looked at the file and Medicare rules. The file shows that the enrollee is not asymptomatic, as there is a personal history of adenomatous polyps. 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 pre-approve Cologuard testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post-stabilization inpatient care provided August 1, 2020 to August 3, 2020.
You asked the Plan to pay for the post-stabilization inpatient care. You say that the services were medically necessary. The Plan denied your request. The Plan says the enrollee was stable for transfer to an in-network facility for further care.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 post-stabilization inpatient care. Our reviewer says that the enrollee was stable for transfer to a plan facility as of 1:36 PM on August 1, 2020. Our physician reviewer found the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan facility for continued inpatient level of care 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 the post-stabilization inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for post-stabilization inpatient care provided August 1, 2020 to August 3, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital services for the enrollee.
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not medically necessary and cannot be approved.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found this hospitalization qualifies for inpatient payment under the two-midnight rule. The documentation indicates a reasonable belief that, at the time of admission, two midnights of care would be required to further evaluate and treat 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for inpatient hospital services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve reduction of osseous tuberosity.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services 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. Therefore, we decided that the Plan does not have to pre-approve reduction of osseous tuberosity.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 9, 2020 to July 23, 2020 by a non-network provider.
You asked the Plan to pay for these services. You say that your primary doctor was not seeing patients. The Plan denied your request. The Plan says the services were rendered by a non-network provider without prior authorization.
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on July 9, 2020 to July 23, 2020 by a non-network provider.