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

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor.
You asked the Plan to pre-approve a Freestyle Libre 14 day sensor. You say that the item is 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. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. 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 Freestyle Libre 14 day sensor. Our reviewer says that the item is not medically necessary. Our physician reviewer found the plan requires insulin use for libre coverage. You do not use insulin nor are we told why you cannot use a glucometer nor if you are having frequent low blood glucose levels to make frequent blood glucose checks a medical necessity. Hence, there is insufficient data to prove medical necessity of the libre. 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 Freestyle Libre 14 day sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit and magnetic resonance imaging (MRI)
to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. You say that you do not want to start over with another
provider. The Plan denied your request. The Plan says the services can be provided by in network 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 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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve an
office visit and magnetic resonance imaging (MRI) to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a device implanted to manage pain (spinal cord stimulator).
You asked the Plan to pre-approve a spinal cord stimulator. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators are only covered for certain 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 a spinal cord stimulator. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic low back pain, sacroiliac joint pain, degenerative disc disease, and trigger points. The enrollee has had Trigger point injections, sacroiliac joint injections, transformianl epidural steroid injections and radiofrequency ablation of medical branch blocks. The enrollee has not had a multi-discplinary approach to pain. The enrollee has not had any psychological evaluation.
The documentation does not provide evidence based indication for performing a spinal cord stimulator trial. 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 spinal cord stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a device implanted to manage pain (spinal cord stimulator).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided on December 26, 2019.
You asked the Plan to waive the copayment for urgently needed services. You say that you feel that the physician assistant did nothing to help you. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 urgently needed services. The medical records show that you received urgently needed services. Therefore, you are responsible to pay the $25 copayment. You have been asked to pay a $25 copayment for urgently needed services. Urgently needed services falls within the urgently needed 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 urgently needed services provided on December 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on November 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab services. You say that would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is out-of-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 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 lab services provided on November 26, 2019 by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Favorable

We decided that the Plan has to pre-approve Prolia.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says that the services are not medically necessary.
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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has osteoporosis with no reported history of osteoporotic fracture. She has tried Fosamax in the past but had side effects of severe heartburn and sharp pains of the right thigh detailed in a May 1, 2020 telemedicine visit). The medication was discontinued and symptoms resolved. She has not tried and failed zoledronic acid. e provided medical records indicate a prior history of sharp thigh pains on Fosamax. Atypical femur fractures with prodromal thigh pain have been reported with bisphosphonates. Such fractures are rare but given the history of this side effect on Fosamax there is concern for similar symptoms with zoledronic acid. For this reason, an exception to the step therapy requirements is necessary in this case. Prolia is reasonable and medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve Prolia.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on November 27, 2019.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says the medical records submitted do not include a signed physician order or signed laboratory requisition for the billed test.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided on November 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the knee brace provided on August 13, 2019.
You asked the Plan to waive the coinsurance for the knee brace. You say that you met your maximum out-of-pocket. You say that you should not have to pay the bill. The Plan denied your request. The Plan says the coinsurance 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 30% coinsurance for each Medicare-covered prosthetic or orthotic device, including replacement or repairs of such devices, and related supplies from an out-of-network provider. You have been asked to pay $169.33, which is 30% coinsurance of the allowed amount for the knee brace. The allowed amount is $564.43 (30% x $564.43 = $169.33). The knee brace falls within the "Prosthetic Devices and Related Supplies" benefit category. The records show that your maximum out-of-pocket had not been met prior to receiving the knee brace. 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 coinsurance for the knee brace provided on August 13, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe cardiac ablation procedure provided from September 11, 2019 to September 12, 2019.You asked the Plan to waive the coinsurance forthe cardiac ablation procedure. You say that you did not know the provider was out-of-network. You say your out-of-pocket maximum is capped at $5,500 and you cannot afford this amount. 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 30% coinsurance for Medicare-covered surgery or other services provided to you at an out-of-network outpatient hospital or other facility charges and physician or surgical charges. You have been asked to pay $6,990.15 which is 30% of the allowed amount for the cardiac ablation procedure. The allowed amount is $23,300.50. ($23,300.50 x 30% = $6,990.15). The cardiac ablation procedure falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows the provider is out-of-network. The record also shows your combined maximum out-of-pocket amount had not been met at the time the service was provided. his 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 coinsurance forthe cardiac ablation procedure provided from September 11, 2019 to September 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS HF system. You asked the Plan to pre-approve a CardioMEMS HF system. You say that the requested CardioMEMS device is medically necessary. The Plan denied your request. The Plan says the requested CardioMEMS device 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 a CardioMEMS HF system. Our reviewer says that the requested CardioMEMS device is not medically necessary. Our physician reviewer found the enrollee is with a history of hypertension, diabetes, hyperlipidemia, chronic kidney disease, obesity, obstructive sleep apnea and Class III congestive heart failure with reduced ejection fraction (LVEF 30%) requiring hospitalization. A request was made for placement of a CardioMems device. In this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational. 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 CardioMEMS HF system have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS HF system.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says your condition can be managed at home, or an assisted living facility with home health
services, or in a long term care facility.
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 services. 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion therapy (S9500) provided on January 23, 2020.You asked the Plan to pay forthe home infusion therapy. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says CPT code S9500 has a status code of I which is invalid for Medicare purposes.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code S9500 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9500 has a status code of I. This means that S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion therapy (S9500) provided on January 23, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (99354) provided October 15, 2019.
You asked the Plan to pay for the psychotherapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the records do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99354 is prolonged evaluation and management or psychotherapy service. We find that CPT code 99354 is not supported in the medical record. Specifically, the record does not support that the services were prolonged or particularly complex. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for psychotherapy services (99354) provided October 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 7, 2018.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 7, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Temazepam capsules.
You asked the Plan to pre-approve Temazepam capsules. You say that you would like the Plan to reconsider
their denial. The Plan denied your request. The Plan says Temazepam capsules are not covered under the
enrollee's Medicare Part B benefit.
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 Temazepam capsules.
Benefits for Temazepam capsules 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam provided on September 6, 2019.
You asked the Plan to pay for the eye exam. You say that the treating physician is not associated with the hospice and provided services as the attending physician. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the eye exam provided on September 6, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on November 30, 2019.
You asked the Plan to waive the copayment for the ER visit. You say that you met your maximum out-of-pocket. You say that you are disputing the bill. 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 $75 copayment for Medicare-covered emergency room visits.
You have been asked to pay a $75 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show that the maximum out-of-pocket was not met prior to the ER visit. 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 ER visit provided on November 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-invasive home ventilator.You asked the Plan to pre-approve a non-invasive home ventilator (E0466).You say that the enrollee needs a home ventilator.The Plan denied your request. The Plan says the medical records do not support the medical necessity required to approve the home ventilator.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 home ventilator (E0466). Our reviewer says that the service is not medically necessary. Our physician reviewer found coverage criteria for a home ventilator are not met.  This enrollee has COPD, although no pulmonary function test results are provided. The enrollee has obstructive sleep apnea, on CPAP. There are no arterial blood gas data while the enrollee is in a stable state, to confirm CO2 retention.  And there are no overnight oximetry data showing hypoxemia at night while on prescribed oxygen.  There is no evidence that BiPAP has been tried and failed.  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 home ventilator (E0466) have not been met.Therefore, we decided that the Plan does not have to pre-approve a non-invasive home ventilator.