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

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that you need the compression stockings as they are helpful to you. The Plan denied your request. The Plan says you do not have a qualifying wound.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6530 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zoster vaccine provided on December 10, 2019.
You asked the Plan to pay for this vaccine. You say that this claim should be paid. The Plan denied your request. The Plan says this claim should be submitted to your Medicare Part D carrier.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide this vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to this vaccine. Therefore, we decided that the Plan does not have to pay for the Zoster vaccine provided on December 10, 2019.
Benefits for this vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on November 22, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on November 22, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says care can be safely provided in the current acute care setting.
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 the admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely
and effectively provide medically necessary and reasonable treatment. The enrollee is comfort care only
without further CHF, antibiotic, fingersticks or insulin care. She has a wound vac but this does not require a
SNF admission. Her needs can be met at a lower level of care and do not require a SNF admission. The
enrollee does not require skilled therapy services with the specialized skill, knowledge and judgment of a
qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF.
The skilled nursing or skilled therapy services (or a combination of these services) are not needed on a "daily
basis" in a SNF. As a practical matter this enrollee does not require the necessary services on an inpatient basis,
in a skilled nursing facility 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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for psychotherapy provided on November 14, 2019.
You asked the Plan to waive the copayment for psychotherapy. You say that this was a follow up for test results. You say that you paid a $35 copayment for that appointment. The Plan denied your request. The Plan says the copayment 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 a $100 copayment for outpatient mental health care at an in-network outpatient hospital. You have been asked to pay a $100 copayment for the psychotherapy. The psychotherapy falls within the "Outpatient mental health care" benefit category. The records show that the psychotherapy was 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 psychotherapy provided on November 14, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Escitalopram Tab 10mg
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says drug coverage is limited to those drugs covered under the medical benefit only.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Escitalopram Tab 10mg
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous and/or interlaminar device for the enrollee for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necesasry. The Plan denied your request. The Plan says medical studies haven't proven that this device is helpful for treatment of the enrollee's health problem.
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 device is not considered medically reasonable and necessary in this case. Our physician reviewer found the device remains experimental. More research is needed to show safety and efficacy. 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 an interspinous and/or interlaminar device for the enrollee for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound provided on December 14, 2019.
You asked the Plan to waive the copayment for the breast ultrasound. You say that you had a mammogram. You say that you shouldn't have a copayment. The Plan denied your request. The Plan says the copayment 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 a $100 copayment for diagnostic radiology. You have been asked to pay a $100 copayment for the breast ultrasound. The breast ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that you were only charged for the diagnostic ultrasound. 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 breast ultrasound provided on December 14, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha SureClick.
You asked the Plan to pre-approve Repatha SureClick. You say that the enrollee has tried other drugs and has shown significant improvement with samples of this drug. The Plan denied your request. The Plan says this drug is not a Part B covered drug and therefore not covered.
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 Repatha SureClick.
Benefits for Repatha SureClick 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 retrobulbar injection provided on December 11, 2019 billed with CPT code 67500.
You asked the Plan to pay for the injection. You say that these were performed by two different providers. The CRNA performs the injection and the physician furnishes the anesthesia services. The Plan denied your request. The Plan says payment for the code 67500 is included in the payment for the overall anesthesia.
The Plan must follow Medicare rules. Medicare rules say that PTP edits which have a modifier of "0" do not allow payment for the Column II code. Code 67500 is a Column 2 code in relation to 00140 and has a modifier indicator of 0. This means that the services are mutually exclusive and cannot both be paid when provided on the same patient in the same encounter. Therefore, we decided that the Plan does not have to pay for the retrobulbar injection provided on December 11, 2019 billed with CPT code 67500.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a respiratory assist device, bi-level pressure capability with humidifier.
You asked the Plan to pre-approve a BiPAP (E0470) with humidifier (E0562). You say that the enrollee needs a BiPAP with humidifier. The Plan denied your request. The Plan says criteria for a BiPAP are not met.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 a BiPAP with humidifier. Our reviewer says that a BiPAP with humidifier is not medically necessary. Our physician reviewer found coverage criteria for a PAP device are not met. Medicare coverage criteria for BiPAP in patients with severe COPD include an arterial pCO2 at least 52 while in a stable state, and hypoxemia at night while breathing the patient's prescribed FiO2. This enrollee's arterial blood gasses were done during a hospitalization for acute respiratory failure, and there is no documentation of hypoxemia at night on oxygen without BiPAP. BiPAP is therefore considered not medically necessary, and the denial is upheld. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a BiPAP with humidifier have not been met. Therefore, we decided that the Plan does not have to pre-approve a respiratory assist device, bi-level pressure capability with humidifier.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mechanical in-exsufflation device for the enrollee.
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the enrollee does not have a diagnosis of a neuromuscular disease with significant impairment of chest wall.
The Plan follows Medicare rules. Medicare rules say that mechanical in-exsufflation devices are only covered under certain medical indications. 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 requested device. Our physician reviewer found that coverage criteria has not been met. This enrollee does not have neuromuscular disease that is impairing movement of the chest wall or diaphragm. Therefore, the requested device is not 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 the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a mechanical in-exsufflation device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the medical services you received on April
4, 2019 and September 25, 2019.
You asked the Plan to waive the cost shares for the services provided. You say that the charges are too high for
a 5-minute visit. The Plan denied your request. The Plan says cost sharing is a contractual obligation and
cannot be waived.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
The file shows that you received a specialist office visit on April 4, 2019, and September 25, 2019. You were
charged a $50 copay for each visit. The visits fall within the physician services benefit category.
You received a stress x-ray on April 4, 2019. You were charged a $14 copay. You also received fluoroscopic
guidance for needle placement. You were charged a 20% coinsurance. The services fall within the outpatient
diagnostic tests benefit category.
The file shows that you received a fluoroscopy and fluoroscopic guidance on September 25, 2019. You were
charged a 20% coinsurance for each service. The services fall within the outpatient diagnostic tests benefit
category. You also received a dexamethasone injection on September 25, 2019. You were charged a 20% coinsurance.
The service falls within the Medicare Part B prescription drug benefit category.
The plan contract says that you pay a cost share each time you receive certain medical services. You have been
asked to pay the correct amounts 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 shares for the medical services you received on April 4, 2019 and September 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI).
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 medically necessary.
The Plan must follow Medicare rules. Medicare rules say that an ESI 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 not medically necessary. Our physician reviewer found the enrollee has chronic low back pain with radiation to her legs. She is doing a home exercise program but there is no documentation of recent physical therapy. There is no recent imaging. She has not had an adequate recent trial of conservative therapy or recent imaging of the lumbar spine; therefore, the ESI is not reasonable or 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 not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI).
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 10,
2019.
You asked the Plan to pay for the testing services. You say that the lab results were requested for further
treatment and management of care. The Plan denied your request. The Plan says the documentation does not
itemize what tests are included in the panel.
The Plan follows Medicare rules. Medicare rules say that controlled substance monitoring and drugs of abuse
testing are only covered under certain medical indications.
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 testing services. Our physician reviewer
found that the enrollee has a history of chronic pain syndrome, sacroiliitis, and lumbar spondylosis. She is
maintained on opiate therapy with Tramadol. The review has determined that the records did not show that the
testing was reasonable and necessary based on patient specific indications, including historical use, medication
response, and clinical assessment. The results were not necessary to make clinical decisions.
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 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 10, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for a specialist office visit provided by a nurse practitioner on September 6, 2019.
You asked the Plan to waive the copayment for a specialist office visit. You say that you were told if you joined the Plan these services would be cheaper. The Plan denied your request. The Plan says that the correct copayment has been applied.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. the Plan has failed to forward the 2019 Evidence of Coverage. Therefore, we decided that the Plan has to waive the copayment for a specialist office visit provided by a nurse practitioner on September 6, 2019.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the insulin injections provided on November 30, 2019 and December 1, 2019.
You asked the Plan to pay for the insulin injections. You say that the charges for the insulin should have been covered under your plan. The Plan denied your request. The Plan says this is not Part B covered. The Plan also says that this drug is self-administered.
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 pay for the insulin injections provided on November 30, 2019 and December 1, 2019.
Benefits for the insulin injections 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat kidney transplant.
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 medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. There are insufficient medical records from a reasonable timeframe
in the submitted documentation to support that the requested repeat transplant meets the criteria for coverage.
The Plan made several attempts to obtain records and received documentation that the enrollee had not been
seen in six months. 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 a repeat kidney transplant.
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 the services are medically necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 you were medically stable with no evidence of need for supervision by a physical medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. You may benefit from further physical therapy (PT) and occupational therapy (OT) but does not require an intensive therapy program. IRF admission is not medically necessary based on your current functional status and medical stability. 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.