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

We decided that the Plan does not have to waive the copayment forthe debridement service provided on September 4, 2019.You asked the Plan to waive the copayment forthe debridement service. You say that the wound care you received is not a surgery. 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 $295 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $295 copayment for the debridement service.You have been asked to pay a $199 copayment for the debridement service. The debridement service falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows that debridement is considered a surgical procedure. 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 forthe debridement service provided by on September 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851,L2397) provided to the enrollee on June 28, 2019.You asked the Plan to pay forthe orthoses. 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. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on June 28,2019.
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 you do not feel that the enrollee will receive the care that she needs and the amount of care that she needsThe Plan denied your request. The Plan says request for acute IRF does not meet the medical necessity criteria. The plan has instead approved admission into a skilled nursing facility.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 based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatmentwith an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have notbeen met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar decompression (63047).
You asked the Plan to pre-approve lumbar decompression (63047). You say that the lumbar decompression surgery is medically necessary. The Plan denied your request. The Plan says the lumbar decompression surgery 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 pre-approve lumbar decompression (63047). Our reviewer says that the lumbar decompression surgery is not medically necessary. Our physician reviewer found the enrollee is with a diagnosis of Spondylolisthesis, in the lumbar region. She is status post posterior decompression at L3-4. The enrollee's symptoms include bilateral hip pain and bilateral low back pain. An MRI on 9/10/19 demonstrated spondylotic changes of the lumbar spine. At L1-2, there was mild bulging of the disc, without herniation or stenosis. At L2-3, there was mild to moderate central canal stenosis, with no focal disc herniation or foraminal stenosis. At L4-5, there was no herniation or stenosis. Transforaminal epidural steroid injections were performed on 2/6/20 at the L2-3 and L5-S1 levels on the right, and at the L5-S1 level on the left. The response to those injections is not documented. The documentation is insufficient to demonstrate that lumbar decompression is medically reasonable and necessary 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 lumbar decompression (63047) have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar decompression (63047).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on May 16, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient hospital services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained for these services.
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 outpatient hospital services provided on May 16, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve125MCG Digoxin Tablets.You asked the Plan to pre-approve the Digoxin. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Digoxin is taken orally and not covered under Medicare Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve 125MCG Digoxin Tablets. Benefits for the Digoxin 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: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveOtezla tab 30mg for the enrollee.You asked the Planto pre-approvethe drug. You say that the enrollee has been on this drug in the past.The Plandenied your request. The Plansaysthis medication falls under Part D coverage.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 Plandoes not haveto pre-approveOtezla tab 30mg for the enrollee.
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 May 16, 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 enrollee has previously received the same supplies within the 5-year RUL.
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or irreparable damage is demonstrated or there has been a change in the enrollee's medical condition. We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the enrollee has received the same durable medical equipment on February 6, 2018. This orthosis is still within the 5-year RUL and the documentation submitted does not show that the orthosis is irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the orthosis at issue. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on May 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Supartz injection to the left knee.You asked the Plan to pre-approvethese services. You say that the services are medically necessary.The Plan denied your request. The Plan says the left knee injection is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have osteoarthritis of the right knee. The records do not show that Supartz is medically necessary for the left knee, as there is no x-ray documentation of osteoarthritis of the left knee. The records do not support that Supartz to the left knee is safe and effective or medically necessary at this time.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-approvea Supartz injection to the left knee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plandoes not have to pre-approve routine transportation services for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no coverage for routine transportation from dialysis in 2020.The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approveroutine transportation services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental surgery, office consultation, and repair tooth socket provided on July 21, 2018.You asked the Plan to pay forthe dental surgery, office consultation, and repair tooth socket. You say that this provider saw the enrollee in the hospital as a trauma patient due to anterior mandibular pain and submental swelling.The Plan denied your request. The Plan says these services are not covered by Medicare or the enrollee's plan.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay forthe dental surgery, office consultation, and repair tooth socket provided on July 21, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) and crowns (D2750) for teeth # 7, 10, 11, 23, 24, 25, and 26.You asked the Plan to pre-approve the dental services. You say that the enrollee is experiencing sensitivity to cold on teeth # 7, 10, 11, 23, 24, 25, and 26. You say that these teeth have decay and 4 walls are broken, not restorable with filling, crowns are necessary to restore the function and health of the enrollee. You also say that the enrollee's teeth are severely damaged due to decay and fracture and that in order to secure the retention of the crowns, building is necessary.The Plan denied your request. The Plan says the x-rays provided do not shows more than 50% of the tooth is weak, broken, missing or with a fracture.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. The Plan covers the dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says that the requested dental services do not meet the criteria for coverage. Our physician reviewer found the documentation provided clearly shows significant attrition of the anterior teeth and it is noted that the teeth in question had all been restored within the past few months. The teeth in question were able to be restored on 11/27/19 with composite resin material, at which time it was not documented that placement of the restorations were questionable. Therefore, the criteria of the Plan have not been met and that the requested procedures are not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met.Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) and crowns (D2750) for teeth # 7, 10, 11, 23, 24, 25, and 26.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from August 2, 2019 to August 5, 2019.You asked the Plan to waive the copayments for the physical therapy visits. You say that you were never informed of any copayment amounts. You say you should not owe the copayments. 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 $40 copayment for each in-network Medicare-covered therapy visit. You have been asked to pay a $40 copayment for each of the physical therapy visits. ($40 x 2 visits = $80). The physical therapy visits fall within the "Outpatient rehabilitation 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 copayments for the physical therapy visits provided from August 2, 2019 to August 5, 2019.Your complaint about being unhappy with the physical therapy services is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60 mg/ml syringe.You asked the Plan to pre-approve Prolia 60 mg/ml syringe. You say that the medical records provided support the necessity of the services in dispute.The Plan denied your request. The Plan says the enrollee does not meet the medical necessity criteria for coverage.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 Prolia 60 mg/ml syringe. Our reviewer says that this enrollee does not meet the criteria. Our physician reviewer found the provided records did not show any evidence of or statement confirming that the enrollee had tried and failed zoledronic acid. There was no supportive evidence provided which would suggest the required zoledronic acid would be less effective or likely have adverse effects for the enrollee. The provided records did not show evidence of renal impairment, conflicting medications, or contraindications to using zoledronic acid use.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia 60 mg/ml syringe have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia 60 mg/ml syringe.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient surgical services provided on December 29, 2017.You asked the Plan to pay forthe surgical services. You say that the services were medically necessary.The Plan denied your request. The Plan says there was no preauthorization for this out-of-network services. The services were not emergent.Medicare rules say that plans can require enrollees to get care from networkproviders. 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 forthe outpatient surgical services provided on December 29, 2017.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEliquis for the enrollee.You asked the Plan to pre-approvethis drug. You say that the enrollee has been successful on this drug since 2017.The Plan denied your request. The Plan says that this is not covered by Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay forself-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-approveEliquis for the enrollee.Benefits for this drugmay 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 pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on November 6, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the enrollee has previously received the same items from a different provider that is still within the 5-year RUL.The Plan must follow Medicare rules. Medicare rules say that the RUL of durable medical equipment is determined through program instructions. In the absence of program instructions, the MAC may determine the RUL of equipment, but in no case can it be less than five years. We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the enrollee has received the same orthoses from a different provider on October 24, 2019. This orthosis is still within the 5-year RUL and the documentation submitted does not show that the orthosis is irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the lumbar-sacral orthosis at issue. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on November 6, 2019.