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

We decided that the Plan has to pay for the anesthesia services (01936).

You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration because this
service was billed correctly per Medicare guidelines. The Plan denied your request. The Plan says that the
diagnosis billed does not support medical necessity.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 pay for the anesthesia services. Our reviewer says
that the requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee has several co-morbidities that justify the attendance of an anesthesiology provider.
These include the presence of anxiety and low pain tolerance that would make the use of local anesthetic alone
unsafe. Furthermore, the enrollee has other systemic co-morbidities that warranted an ASA 3 classification.

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 anesthesia services have been met. Therefore, we decided that the Plan has
to pay for the anesthesia services (01936)

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 for the vitamin D testing provided to the enrollee.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says screening tests are not
covered.

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 testing at issue in this appeal, the vitamin D assay, 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 vitamin D testing provided to the enrollee
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (84439) provided July 29, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the number of units billed exceeds the allowed amount.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value for the HCPCS/CPT code will be denied.

In this case, the MUE for CPT code 84439 is 1. You billed 2 units of this code, exceeding the MUE. Based on
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore,
we decided that the Plan does not have to pay for lab services (84439) provided July 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the full mouth x-ray (D0210) provided on October 8, 2020.

You asked the Plan to pay for the dental services. You say that you have an extreme financial hardship. You say that you received a bill for $260 which you are not able to pay. You also say that you would like these services to be considered as a write off. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 years. The Plan says that 1 full mouth x-ray is covered every 5 years. The Plan also says that the frequency limits for these services have been exceeded.

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, the frequency limits for these services have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation and a full mouth x-ray that you received on March 2, 2020. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the full mouth x-ray (D0210) provided on October 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs provided on August 25, 2020.

You asked the Plan to pay for self-administered drugs. You say that you were told not to bring your own
medications into the hospital, and if you had been told you were a hospital outpatient you would have taken
your medications before arriving at the hospital. The Plan denied your request. The Plan says the denial of
payment for these drugs is correct, because these drugs are not covered by Medicare Part B.

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 pay for self-administered drugs provided
on August 25, 2020.

Benefits for self-administered drugs 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services.

You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you are unhappy with the outcome of the therapy. 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 $40 copayment for outpatient rehabilitation services.

You have been asked to pay a $40 copayment for outpatient rehabilitation services. Outpatient rehabilitation services 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 copayment for outpatient rehabilitation services.

We note your complaint that you are unhappy with the outcome of the therapy you received. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio.

You asked the Plan to pre-approve Entyvio. The Plan denied your request. The Plan says the enrollee has not tried and failed a tumor necrosis factor, corticosteroids, or immunomodulators.

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 Entyvio. Our physician reviewer found that the enrollee has a history of Crohn's disease. the documentation indicates that the enrollee has mild disease and that he does not have symptoms and that he has responded well to Mesalamine. The Plan requires a trial of a tumor necrosis factor, corticosteroids, or immunomodulators before they will approve the requested drug. The documentation does not show that the enrollee has tried and failed the required drugs. The documentation does not show that the Plan's required drugs will likely be less effective, or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for 1-month supply allowance for therapeutic continuous glucose monitor (K0553) provided on January 23, 2020, by an out of network (OON) provider.

You asked the Plan to pay for 1-month supply allowance for therapeutic continuous glucose monitor. You say that these services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained for the services rendered by an OON provider.

The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. 

The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for 1-month supply allowance for therapeutic continuous glucose monitor (K0553) provided on January 23, 2020, by an out of network (OON) provider.
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 are at risk for falls. The Plan denied your request. The Plan says the services are not medically necessary.

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 medically necessary. Our physician reviewer found that your medical status does not require intensive physician or nursing supervision in an IRF. Your hemoglobin level is stable. Your kidney insufficiency is improved and your blood pressure is stable. While you may benefit and participate in multiple therapies, your functional level does not require this on an intensive rehabilitation therapy program provided in an IRF. 

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The
Plan denied your request. The Plan says the services can be obtained at the current level of care they are
receiving.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not
available at the health care setting being offered by the health plan. The requested LTACH services are not
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services have not been met. The enrollee is able to receive equal
level of care where the currently are. This means care at a LTACH is not medically necessary or reasonable.
Therefore, we decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH)
services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not need three hours of therapy a day, and her medical illness are stable.

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 physician reviewer found that the enrollee was admitted to the acute hospital for dizziness and weakness. Her medical conditions are stable There are no medical needs requiring inpatient admission. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. 

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: 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 IRF care is necessary to for you to regain maximum functioning. The Plan denied your request. The Plan says IRF care is not medically necessary.

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 the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, the patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. Finally, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo for the enrollee.

You asked the Plan to pre-approve Opdivo. You say that this treatment is recommended for the enrollee. The Plan denied your request. The Plan says that the clinical value and effectiveness of Opdivo in the setting of cutaneous angiosarcoma have not been demonstrated in the peer-reviewed literature.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Opdivo. Our reviewer says that Opdivo is not medically reasonable and necessary for the enrollee. Opdivo is not FDA-approved for the enrollee's diagnosis. The use of Opdivoc is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for coverage of Opdivo. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve hyperbaric oxygen therapy.

You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that the requested hyperbaric oxygen therapy is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for the requested hyperbaric oxygen therapy.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 hyperbaric oxygen therapy. Our reviewer says that the enrollee meets criteria for the requested hyperbaric oxygen therapy. Our physician reviewer found the review indicates that the enrollee has a Grade IV diabetic foot ulcer on his right great toe. He has failed standard wound care and debridement. His provider has requested hyperbaric oxygen therapy. Based on the documentation provided, the enrollee has a covered indication for the requested hyperbaric oxygen therapy and meets Medicare criteria.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of hyperbaric oxygen therapy have been met. Therefore, we decided that the Plan has to pre-approve hyperbaric oxygen therapy.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that you cannot stand in the shower. The Plan denied your request. The Plan says that this item is not a covered item.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Dexcom therapeutic glucose monitor.

You asked the Plan to pre-approve the Dexcom therapeutic glucose monitor. You say that this service is
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says criteria for
therapeutic glucose monitors has not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood
glucose testing at least four times per day and does not use insulin with at least three daily injections. Based on
this information, we decided that Medicare rules for coverage of the Dexcom therapeutic glucose monitor have
not been met. Therefore, we decided that the Plan does not have to pre-approve the Dexcom therapeutic
glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-network oncologist.

You asked the Plan to pre-approve the medical services. You say that the enrollee is an established patient with the provider and needs additional follow-up. The Plan denied your request. The Plan says the medical records received did not show that the enrollee has an emergent or urgent medical condition, or are in need of specialized services. The Plan states there are fifteen (15) in-network provider(s) within a reasonable distance from the enrollee's location that can provide 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 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-approve the medical services to be provided by an out-of-network oncologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5261) purchased March 9, 2020, from an out of network (OON) provider.

You asked the Plan to pay for the hearing aids. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says a referral must be obtained before you receive routine or elective medical services from an OON provider.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are purchased from in-network providers. 

We looked at this the file and the Plan's rules. The file indicates that these services were provided by an OON provider without prior authorization. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5261) purchased March 9, 2020, from an out of network (OON) provider.