Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical nutrition therapy services provided to the enrollee on November 20, 2019.You asked the Plan to payforthe medical nutrition therapy services. The Plan denied your request. The Plan says this is not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. The records do not show that the enrollee suffers from renal disease or diabetes.Therefore,we decided that the Plan does not have to pay forthe medical nutrition therapy services provided to the enrollee on November 20, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not havetopre-approveadmission to a skilled nursing facility (SNF) for the enrollee.You asked the Planto pre-approvethe admission. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee is eligible for custodial nursing care, outpatient therapy (less than five times a week) and restorative care.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for 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 Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF) for the enrollee
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a GEL-ONE injection for left knee.
You asked the Plan to pre-approve a GEL-ONE (J7326) injection for left knee. You say that the previous
treatment made the enrollee's knee worse. The Plan denied your request. The Plan says the enrollee has not first
tried and had a contraindication or intolerance to Orthovisc and Monovisc.
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 a GEL-ONE (J7326) injection for left
knee. Our reviewer says that this drug is not medically necessary. Our physician reviewer the enrollee has a
diagnosis of unilateral primary osteoarthritis of the left knee. The enrollee has not tried and failed the required
drugs. The documentation does not support that Monovisc and Orthovisc (Hyaluronic acid) would likely be
less effective, and/or would likely have adverse effects for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a GEL-ONE (J7326) injection for left knee have not been met. Therefore, we
decided that the Plan does not have to pre-approve a GEL-ONE injection for left knee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging of the Cervical Spine (72141).
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 MRI. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the records show a principal diagnosis of thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm. Magnetic imaging studies of the cervical spine is not indicated for the noted diagnosis. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging of the Cervical Spine (72141).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete lower denture (D5120).
You asked the Plan to pre-approve a complete lower denture. You say that the enrollee needs a new lower denture. The Plan denied your request. The Plan says dentures are covered only once every five years.
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, coverage of dentures is limited to one complete or partial denture every five years. The record shows that the enrollee previously received a complete lower denture in 2017. Therefore, we decided that the Plan does not have to pre-approve a complete lower denture (D5120).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulicity.You asked the Plan to pre-approve the Trulicity. You say that the desired results for the enrollee on this medication has been well.The Plan denied your request. The Plan says the enrollee does not have a pharmacy benefit with the Plan and Trulicity is covered by the pharmacy 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 Trulicity.Benefits for the Trulicity 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 pre-approve a non-invasive home ventilator (E0466).
You asked the Plan to pre-approve a non-invasive home ventilator. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says the records provided do not support the requested service.
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 non-invasive home ventilator. Our reviewer says that this enrollee does not meet the Medicare coverage criteria. Our physician reviewer found this enrollee has severe COPD and is on oxygen, but there are no results of arterial blood gas testing to indicate CO2 retention. Further, the ventilator is to be used as a BiPAP device, which is not covered by Medicare. Certain BiPAP devices are capable of providing the AVAPS-AE mode. There is no evidence of BiPAP failure. A home ventilator is 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 non-invasive home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a non-invasive home ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on December 13, 2019.You asked the Plan to waive the copayment for the ultrasound. You say that this was a part of your annual physical. You say that this has always been covered in full.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 $250 per day for Medicare-covered diagnostic radiology services. You have been asked to pay $75.55, which is less than the standard $250 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 ultrasound provided on December 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forfoot orthotics.You asked the Plan to pay forfoot orthotics. You say that you have problems with your legs, feet and back. You say that you are hoping that the orthotics are going to help solve the problems that you are encountering and you believe the Plan should cover at least part of the cost of the orthotics.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 pay forfoot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on November 15, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services are available in-network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with thePlan 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 services at issue in this appeal. 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 haveto pay forthe medical services provided to the enrollee by an out-of-network provider on November 15, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).You asked the Plan to pre-approve the admission. You say that this is medically necessary.The Plan denied your request. The Plan says complex daily skilled nursing care and daily skilled rehab therapy are not required.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 there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for 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 (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on January 6, 2020.
You asked the Plan to waive the copayment for the eye exam. You say that this was an annual exam. You say that there was no medical treatment or diagnostic service during the exam. 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 $35 copayment per visit for exams of the eye related to a medical condition. You have been asked to pay a $35 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The records show the medical eye exam was due to a diagnosis of diabetes and cataracts. 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 eye exam provided on January 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zolpidem Tartrate.
You asked the Plan to pre-approve Zolpidem Tartrate. You say that the medication has been working. The Plan denied your request. The Plan says Zolpidem that you take orally is not a covered 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 Zolpidem Tartrate.
Benefits for Zolpidem Tartrate 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe train of four testing provided on December 6, 2018.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this is a bundled service.The Plan must follow Medicare rules. Medicare rules say that all services which are integral to accomplishing a procedure are considered a component part of a comprehensive code.IONM services cannot be performed without TOF monitoring. This means that TOF testing is considered integral to the performance of IONM services. As such, this component of the procedure is included in payment for the overall IONM monitoring service which was already paid. No separate payment can be made for this part of the service. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forthe train of four testing provided on December 6, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation system to be provided by an out of network (OON) provider.You asked the Plan to pre-approve a high frequency chest wall oscillation system. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that medically necessary care is available in network.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-approvea high frequency chest wall oscillation system to be provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional physical therapy visits.You asked the Plan to pre-approveadditional physical therapy visits. You say that the additional physical therapy visits are medically necessary.The Plan denied your request. The Plan says the additional physical therapy visits are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee is with low back pain, chronic in nature. History is notable for neuromyelitis optica; the enrollee has received physical therapy (PT) dating back to at least February 2020. Treatments have included modalities, neuromuscular reeducation, strengthening, and home exercise program education. For back pain, physical therapy (PT) is generally accepted as specific and effective therapy. Goals include reducing pain, restoring function, and educating regarding a home exercise program (HEP) prior to transition towards a home program. In this case, there is no indication prior PT has served to provide sustained, significant improvement in pain and/or function and there is no indication residual deficits could not be addressed via a home exercise program. Therefore, this request is deemed 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 additional physical therapy visits have not been met.Therefore, we decided that the Plan does not have to pre-approveadditional physical therapy visits.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 admission to an IRF does not meet criteria. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The records reveal her conditions are stable and are not so complex that they need intensive physician and nursing oversight in an IRF. The enrollee requires treatment by multiple therapies such as physical therapy, occupational therapy and speech therapy but the documentation does not support that she needs this therapy on an intensive rehabilitation therapy program level. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF due to her persistent lung physical exam with crackles, ongoing dyspnea with exertion and requiring multiple rest breaks in 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower denture (D5214).
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says that your request exceeds the allowable benefit limitation.
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. We looked at the case file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the dentures have not been met. Specifically, you have previously received a complete upper denture and a lower partial denture on October 15, 2018. The Plan benefit allows for only one set of complete or partial dentures every five years. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower denture (D5214).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 99190) provided on January 20, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says payment for this services is included in the Part A DRG payment to the facility.The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim.Therefore, we decided that the Plan does not have to pay forthe services (CPT 99190) provided on January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea referral to provider an out-of-network provider.You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services are available in-network.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 Plandoes not haveto pre-approvea referral to provider, an out-of-network provider.