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

We decided that the Plan does not have to pay for the Coronavirus testing provided on December 15, 2020.
You asked the Plan to pay for the Coronavirus testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the claim must be submitted to the enrollee's primary insurer.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the Coronavirus testing until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the Coronavirus testing provided on December 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing (81162).
You asked the Plan to pre-approve BRCA1 and BRCA2 genetic testing. You say that this is necessary due to your family history. The Plan denied your request. The Plan says this is only covered for a personal history of cancer.
The Plan must follow Medicare rules. Medicare rules say that RCA1 and BRCA2 genetic testing is considered medically necessary for a beneficiary with a current diagnosis or a personal history of a cancer associated with the BRCA mutation. We looked at the file and Medicare rules. The records show that your do not have aa current diagnosis or a personal history of cancer. Based on this information, we decided that Medicare rules for coverage of BRCA1 and BRCA2 genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing (81162).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous vertebral augmentation (PVA) (22514).
You asked the Plan to pre-approve a PVA. You say that the service is medically necessary. The Plan denied your request. The Plan says clinical documentation provided reports the members pain scale was rated at a 4/10 on a 0-10 scale. As per Local Coverage Determination LCD - Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L35130) To meet criteria for the procedure requested, clinical documentation provided must indicate that the members pain is rated as a 5/10 on a 0-10 pain scale or greater.
The Plan must follow Medicare rules. Medicare rules say that PVA procedures will be considered medically reasonable and necessary if the beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating Scale [NRS] or Visual Analog Scale [VAS] pain score of greater than or equal to 8) or is non-hospitalized with moderate to severe pain (NRS or VAS of greater than or equal to 5). We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PVA have not been met. Specifically, the enrollee's pain scale was not at a 5 or greater. This means the requested service is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve a percutaneous vertebral augmentation (PVA) (22514).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio.
You asked the Plan to pre-approve Entyvio. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
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 Entyvio. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has a diagnosis of ulcerative colitis. The documentation does not support that the enrollee has tried and failed Stelara. The documentation does not support an indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 based on the medical records provided there is no documentation that the enrollee requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. This enrollee does require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. This enrollee does not require the services on an inpatient basis, only in a SNF setting. Services in a long-term care facility on a part time basis appear appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Levalbuterol HFA aerosol.
You asked the Plan to pre-approve Levalbuterol HFA aerosol. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.
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 Levalbuterol HFA aerosol.
Benefits for Levalbuterol HFA aerosol 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that inpatient rehabilitation is necessary for your condition to improve. The Plan denied your request. The Plan says the criteria for admission to an IRF have not been met. Your ongoing skilled therapy and nursing needs can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the bilateral facet joint injections requested to treat back pain (CPT code(s): 64493, 64494, and 64495).
You asked the Plan to pre-approve the injections. You say that you are in constant pain, cannot walk very well, have fall several times and cannot walk more than twenty (2) feet at a time without stopping because of the pain. The Plan denied your request. The Plan says these injections are only covered if done separately from other injections procedures and if done at two or fewer levels of the spine. The Plan states the records from your doctor also indicated that your doctor was planning epidural steroid injections to treat your back pain and was planning facet joint injections at three separate levels of the spine.
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 physician reviewer found criteria for facet injection not met. You have documented radicular pain which is a contraindication to facet injection therapy. 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve the bilateral facet joint injections requested to treat back pain (CPT code(s): 64493, 64494, and 64495).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311) and power seat elevation feature (E2300)
You asked the Plan to pre-approve an expandable controller and power seat elevation feature. You say that these items are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met for the expandable controller and the power seat elevation feature is statutorily not covered.
The Plan follows Medicare rules. Medicare rules say that an expandable controller is subject to the rules listed in the Medicare rules section. The rules also say that a power seat elevation feature is statutorily non-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 an expandable controller and power seat elevation feature. Our reviewer says that the requested expandable controller is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 65-year-old female with a past medical history of limb-girdle muscular dystrophy who requires a power wheelchair for mobility. Based on the medical records provided there is no documentation that meets Medicare criteria for coverage of the requested expandable controller. Available records indicate the enrollee has 4/5 upper extremity strength and is able to feed herself thus indicating she has adequate upper extremity strength and function to control the power options with their own 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 an expandable controller have not been met. In addition, the power seat elevation feature requested is statutorily non-covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311) and power seat elevation feature (E2300)
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the member needs to regain the ability to function. The Plan denied your request. The Plan says that the member does not need daily skilled nursing or rehabilitation therapy.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99203) provided on February 19, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $50 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office.

You have been asked to pay a $50 copayment for the specialist office visit provided. 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 office visit (99203) provided on February 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the requested device. You say that you have unstable dysglycemia. The Plan denied your request. The Plan says you are not being treated with insulin.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation does not indicate that you use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva (J0897).
You asked the Plan to pre-approve Xgeva (J0897). You say that you want to treat the enrollee with this drug. The Plan denied your request. The Plan says the enrollee has not first tried and failed zoledronic acid.
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 Xgeva (J0897). Our reviewer says that the drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has not tried and failed the required drug. There is no indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the patient. Based on guidelines in the major Medicare-approved drug compendia, a creatinine clearance of 54 mL/minute is not a contraindication to the use of intravenous zoledronic acid. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Xgeva (J0897) have not been met. Therefore, we decided that the Plan does not have to pre-approve Xgeva (J0897).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve an upper eyelid blepharoplasty.
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 that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that blepharoplasty is covered when specific criteria are met. 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has a marginal reflex distance (MRD1) of 2.5 on the left. The records indicate significant improvement in visual field testing with taping and that the surgery is being requested for a functional reason. The criteria for coverage are met and the requested upper eyelid blepharoplasty is reasonable and medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve an upper eyelid blepharoplasty.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Magnetic Resonance Imaging (MRI) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a MRI. You say that the service is medically necessary. The Plan denied your request. The Plan says there is not a physician order from your primary care physician.

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 a Magnetic Resonance Imaging (MRI) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950).
You asked the Plan to pre-approve the core buildup. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit plan.
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 a core buildup, including any pins when required (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services with an oral surgeon.
You asked the Plan to pre-approve dental services with an oral surgeon. You say that you were referred to an oral surgeon for extractions. You say that you have been taking Tylenol and Ibuprofen and you can no longer handle the pain. The Plan denied your request. The Plan says services with an oral surgeon are not a covered benefit under the enrollee's contract.
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, this benefit is limited to services performed by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve dental services with an oral surgeon.