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

We decided that the Plan does not have to pay forthe Guardant360 testing provided on March 30, 2019.You asked the Plan to pay forthe Guardant360 testing. The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the Guardant360 testing. Our reviewer says that the requested Guardant360 testing is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has a diagnosis of infiltrating ductal carcinoma with positive lymph nodes. The documentation supports the enrollee has undergone some genomic testing. The documentation does not discuss a care plan or treatment selection based on Guardant360 testing. Without the support of the documentation, medical necessity cannot be determined.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 Guardant360 testing have not been met.Therefore, we decided that the Plan does not have to pay forthe Guardant360 testing provided to on March 30, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (J7318).
You asked the Plan to pre-approve Durolane. You say that the requested medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met.
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 Durolane. Our reviewer says that the medication is not medically necessary. Our physician reviewer found Monovisc has been tried. The Plan requires a trial of both Orthovisc and Monovisc before they will approve the requested drug. The documentation does not support that Orthovisc 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 Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane (J7318).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana (J7605).
You asked the Plan to pre-approve Brovana. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support the medical necessity for a step therapy exception.
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 Brovana. Our reviewer says that the member has not tried and failed a trial of Perforomist. Our physician reviewer found the documentation does not support that Perforomist would likely be less effective, and/or would likely have adverse effects.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Brovana have not been met. Therefore, we decided that the Plan does not have to pre-approve Brovana (J7605).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xeljanz tablets.
You asked the Plan to pre-approve self-administered drugs. You say that the enrollee has tried and failed other medications, so this is medically necessary. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
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 Xeljanz tablets.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Basaglar kwikpen.
You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says coverage is limited to Medicare Part B covered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Basaglar kwikpen.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve naturopath services to be provided by "the provider". You asked the Plan to pre-approve the naturopath services. You say that you live on "the island" and the only way to get on and off the Island is with a Ferry, which takes 1.50 hours one wayto see a doctor in Seattle. Yousay that "the provider" is linked to those with the Plan's PPO plan. The Plan denied your request. The Plan says the only exception to seeing non-network providers is for emergency services.Medicare rules say that plans can require enrollees toget 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 pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan doesnot have to pre-approve naturopath services to be provided by "the provider".
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health service provided on April 3, 2019 to April 30, 2019 by out of network provider
You asked the Plan to pay for home health service. You say that the provider provides these services in good faith for the medically necessary service. The Plan denied your request. The Plan says no prior authorization was obtained.
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 has network providers available who can provide 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 home health service provided on April 3, 2019 to April 30, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora chiropractic office visit (99202), electrical stimulation (97032), and an x-ray (72040) provided from September 4, 2019 to September 27, 2019.You asked the Plan to pay fora chiropractic office visit, electrical stimulation, and an x-ray. You say that these services were medically necessary.The Plan denied your request. The Plan says these services are not covered when provided by a chiropractor.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay fora chiropractic office visit (99202), electrical stimulation (97032), and an x-ray (72040) provided from September 4, 2019 to September 27, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not haveto pay foran annual wellness visit received on September 12, 2019.You asked the Planto pay forthe visit. You say that this should be paid for.The Plandenied your request. The Plansaysthe same service was already done on April 4, 2019.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 annual wellness visits are covered once every calendar year. The file shows that you had an annual wellness visit on April 4, 2019. The visit at issue in this case -done on September 12, 2019, is a benefit exhaustion.Therefore, we decided that the Plandoes not haveto pay foran annual wellness visit received on September 12, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on June
14, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you cannot afford to pay
for this. The Plan denied your request. The Plan says that this processed 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 a $150
copayment for Ambulance services.
You have been asked to pay a $150 copayment for the ambulance transport. The ambulance transport falls
within the Ambulance services benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for
the ambulance transport provided on June 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitoring system.
You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee needs a continuous glucose monitor. The Plan denied your request. The Plan says criteria have not been met for a CGM.
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 looked at the file, and Medicare rules. The record shows the enrollee does not test four or more times a day or injects insulin three or more times a day. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitoring system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $10 copayment for physician services.
You asked the Plan to waive . You say that this copayment is not correct. The Plan denied your request. The Plan says this copayment was applied based on the services provided and the Plan contract agreement.
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 physician or office visit services. 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 $10 copayment for physician services.
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. You say that the medication is medically necessary.The Plan denied your request. The Plan says they are not responsible for covered routine costs associated with clinical trials.The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services.In this case, you asked the Plan to pre-approve Xgeva as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials.Therefore, we decided that the Plan does not have to pre-approveXgeva (J0897)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on to the enrollee on September 23, 2019.You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan mustpay 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 has network providers available who can provide 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 thePlan does not have to pay forthe medical services provided on to the enrollee on September 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services
You asked the Plan to pre-approve the physician's services. You say that this physician does arthritis research and was able to access a pharmaceutical program for your medication for 2020. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the specialist office visit, the insert, the skin lesion trimming, or the nail debridement provided on August 1, 2019.
You asked the Plan to waive the cost share for the specialist office visit, the insert, the skin lesion trimming, and the nail debridement. You say that you do not remember receiving the skin lesion trimming and the nail debridement. You say you are being charged for services you did not receive. 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 $25 copayment for an in-network specialist visit, 15% of the cost for in-network durable medical equipment, and 20% of the cost for in-network Medicare-covered podiatry services.
You have been asked to pay a total of $84.10 for the specialist office visit, the insert, the skin lesion trimming, and the nail debridement. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The insert falls within the "Durable medical equipment (DME) and related supplies" benefit category. The skin lesion trimming and the nail debridement fall within the "Podiatry services" benefit category. The record shows you received the skin lesion trimming and the nail debridement services. See chart below.
Date of Service
Service
Allowed Amount
Copayment/Coinsurance
Member Liability
August 1, 2019
Specialist office visit
$47.09
$25.00
$25.00
August 1, 2019
Insert
$267.36
15%
$40.10
August 1, 2019
Skin lesion trimming
$71.09
20%
$14.22
August 1, 2019
Nail debridement
$47.75
20%
$4.78 - This less than the standard coinsurance amount.
Total
$84.10
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 specialist office visit, the insert, the skin lesion trimming, or the nail debridement provided on August 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neupro patches. You asked the Plan to pre-approve Neupro. You say that the enrolleewill likely have poor compliance with oral therapies.The Plan denied your request. The Plan says Neupro to be taken at home is not covered under the Part B 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-approveNeupro patches.Benefits for Neupromay be available under Medicare Part D.Contactthe 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 the seat lift mechanism of a seat lift chair.You asked the Plan to pre-approve the seat lift mechanism. You say that the enrollee is unable to stand from a chair. The Plan denied your request. The Plan says the enrollee does not have severe arthritis of the hip or knee, or have a severe neuromuscular disease.The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met.Medicare does not cover the upholstered portion of a seat lift chair.We looked at the file, and Medicare rules. The medical record does not show the enrollee has severe arthritis of the hip or knee, or have a severe neuromuscular disease. Based on this information, we decided that Medicare rules for coverage of the seat lift mechanism have not been met.Therefore, we decided that the Plan does not have to pre-approve the seat lift mechanism of a seat lift chair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and supplies.
You asked the Plan to pre-approve a CGM and supplies. You say that this would be easier and safer for you to use. The Plan denied your request. The Plan says that you are not treated with insulin.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above criteria have been met. We looked at the file and Medicare rules. The file indicates you are not treated by insulin injections. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and supplies.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Procrit injection (J0885) to be administered by an out of network provider.
You asked the Plan to pre-approve this service. You say that you are requesting reconsideration of the Plan's denial. The Plan denied your request. The Plan says this service is available within the Plan's network of providers.
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 pre-approved care. The physician in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. We found no exception that would require the Plan to pre-approve these service. Therefore, we decided that the Plan does not have to pre-approve a Procrit injection (J0885) to be administered by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that your current orthotic is worn out and you have to use a cane to walk due to loss of balance. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.