Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cosopt PF eye drops.
You asked the Plan to pre-approve Cosopt PF eye drops. You say that the eye drops are medically necessary for treatment of the member's condition. The Plan denied your request. The Plan says this drug is not covered under the member's Medicare Part B benefits.
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 Cosopt PF eye drops.
Benefits for Cosopt PF eye drops 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forhearing aids provided on June 18, 2019.You asked the Plan to pay forthe hearing aids. You say that you respectfully ask review of the information concerning hearing aid reimbursement.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network 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 you must go to "in network" to provide hearing aid benefits. We looked at this the file, and the Plan's rules. 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 haveto pay forhearing aids provided on June 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecustom myoelectric elbow-wrist-hand-finger orthosis (MyoPro Motion G) provided to the enrollee on .You asked the Plan to pre-approvethe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says there is not enough published evidence showing that the MyoPro G is safe to use and will positively impact the member's health outcome. Further studies are needed to establish clinical effectiveness and long-term safety of the device.The Plan follows Medicare rules. Medicare rules say that services that are experimental or investigational do not meet coverage criteria. 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 orthosis. Our reviewer says that the orthosis is not medically necessary. Our physician reviewer found this device has not been proven to be medically necessary; more research is needed to determine efficacy. The device is experimental or investigational. Further research demonstrating the clinical benefit of such a myoelectric orthosis is warranted.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 orthosis have not been met.Therefore, we decided that the Plan does not have to pre-approvecustom myoelectric elbow-wrist-hand-finger orthosis (MyoPro Motion G) provided to the enrollee on
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive pharmacogenomics panel provided to the enrollee on May 29, 2019.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says there are no symptoms or diagnoses that would be identified or modified by this testing.
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 pay for the testing. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found based on the medical records provided the comprehensive pharmacogenomics panel in this case is not medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive pharmacogenomics panel provided to the enrollee on May 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 2, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require prior authorization.
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 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 have to pay for physician's services provided on October 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora shoulder-hand-wrist orthosis (L3960) provided to the enrollee on October 1, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.ThePlan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The rules say for Medicare to consider coverage and payment for any item or service, the information submittedby the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary and conducted a face-to-face assessment.Therefore, we decided that the Plan does not have to pay fora shoulder-hand-wrist orthosis (L3960) provided to the enrollee on October 1, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay forthe periodic oral evaluation (D0120), the bitewing x-rays (D0274), and the periodontal scaling and root planing (D4341) for all 4quadrants provided on September 11, 2019.You asked the Plan to pay forthe dental services. You say that the provider did not tell you what he was doing.The Plan denied your request. The Plan says that the annual maximum of $650 has been reached.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan paid $480 of the total $595 for the services you received on September 11, 2019 claiming that your annual maximum benefit of $650 per year has been reached. There is no documentation that substantiates that the annual maximum benefit has been reached.Therefore, we decided that the Plan has to pay forthe periodic oral evaluation (D0120), the bitewing x-rays (D0274), and the periodontal scaling and root planing (D4341) for all 4 quadrants provided on September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on October 21, 2019.
You asked the Plan to waive the copayment for an office visit. You say that you went for your annual wellness exam. You say that you should not have a copayment for this. The Plan denied your request. The Plan says the correct copayment has been applied to the office visit that was provided.
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 $10 copayment for physician/practitioner services/primary care physician. You have been asked to pay a $10 copayment for an office visit. Since a follow-up visit was provided, the correct copayment has been applied. An office visit falls within the physician/practitioner services/primary care physician 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 an office visit provided on October 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe singlepulse transcranial magnetic stimulation (STMS) mini device (E1399).You asked the Plan to pre-approveSTMS device. You say that this device is needed to help treat the enrollee's headaches.The Plan denied your request. The Plan says the device is considered experimental and investigational and therefore not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of STMS device have not been met.Therefore, we decided that the Plan does not have to pre-approvethe single pulse transcranial magnetic stimulation (STMS) mini device (E1399)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Invokana 100mg tablet medication.
You asked the Plan to pre-approve this medication. You say that this medication is medically necessary to treat
the enrollee's condition. The Plan denied your request. The Plan says this medication is not a covered benefit
under the member's contractual policy.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drug requested here is not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Invokana 100mg tablet
medication.
Benefits for this medication may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radio frequency ablation (64636 and 64635).You asked the Plan to pre-approve the radio frequency ablation. You say that the service is medically necessary for the treatment of your condition. The Plan denied your request. The Plan says only two sessions are allowed in any rolling 12-month year and you previously received a session on June 5, 2019 and June 26, 2019.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you had 2 separate RFA sessions as opposed to one bilateral session. Because the procedure was done as two separate sessions, the request exceeds the utilization criteria of the LCD.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 radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (64636 and 64635)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for IRF care has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not meet criteria for IRF admission. You are medically stable with no evidence of need for supervision by a Physical Medicine and Rehabilitation (PMR) Physician or needs acute rehab nursing care. You may benefit from further physical therapy (PT) and occupational therapy (OT) but do not require an intensive therapy program. IRF admission is not medically necessary based on your current functional status, low endurance and medical stability. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe x-ray provided on September 4, 2019.You asked the Plan to waive the copayment forthe x-ray. You say that the plan only paid $4.13 leaving a balance of $100.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for basic radiological services at an in-network outpatient hospital. You have been asked to pay a $100 copayment for the x-ray. The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 forthe x-ray provided on September 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a transthoracic echocardiograph (C8929, Q9957) provided July 26, 2019
You asked the Plan to waive the coinsurance for the echocardiography. You say that the coinsurance should be waived. The Plan denied your request. The Plan says the correct cost sharing has been applied.
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% coinsurance for advanced diagnostic testing. You have been asked to pay a 35% coinsurance for the echocardiography. The echocardiography falls within the advanced diagnostic testing 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 coinsurance for a transthoracic echocardiograph (C8929, Q9957) provided July 26, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99232) provided on August 19, 2019.
You asked the Plan to pay for hospital care. You say that this should be reconsidered and paid. The Plan denied your request. The Plan says payment for this service was included in payment for the surgical procedure.
The Plan must follow Medicare rules. Medicare rules say that when the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine pre-operative service and a visit or consultation is not billed in addition to the procedure. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of hospital care have not been met. Specifically, the decision to perform the minor procedure (93459), which has a 000-day global surgery period, was done immediately before the procedure during the E/M service at issue. It is considered to be a routine pre-operative service and should not be billed in addition to the procedure. Therefore, we decided that the Plan does not have to pay for hospital care (99232) provided on August 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided September 27, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was warranted and supported by clinical documentation in the medical chart. The Plan denied your request. The Plan says the member had fistulagram and balloon angioplasty which are ambulatory surgical procedures. There was no post procedure instability therefore the surgical exception criteria was not met.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the emergency department (ED) on September 27, 2019 complaining of right sided chest pain for 3 days. Her pain level was 8/10. She was scheduled for a procedure due to arteriovenous fistula (AVF) stenosis. Post procedure, she was monitored for level of pain, diet tolerance, and post procedural bleeding. She was discharged home later that day to the care of her daughter in stable condition. Outpatient follow up instructions were provided. The review has determined that the admission was not warranted and supported by clinical documentation in the medical chart. Based on the documentation in the
medical record, it was not reasonable for the admitting physician to expect that the enrollee's necessary hospital care would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided September 27, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on October 9, 2019.
You asked the Plan to pay for the eye refraction. You say that you see two eye specialists and this provider sees you for major issues with your eyes. The Plan denied your request. The Plan says you have exceeded the benefit limits.
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.
We looked at the file and the Medicare rules. The file shows that you received an eye exam for a Medicare-covered eye condition and not a routine eye exam. The file shows that part of this exam was for a refraction. Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on October 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forbilateral knee orthoses (L1833), lumbar-sacral orthosis (L0650) and suspension sleeves (L2397) provided to the enrollee on September 16, 2019.You asked the Plan to pay forthe orthoses and sleeves. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.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 orthoses and sleeves. Our reviewer says that the enrollee does not meet criteria for the orthoses and sleeves ordered. Our physician reviewer found the 
documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there isinsufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.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 orthoses and sleeves have not been met.Therefore, we decided that the Plan does not have to pay forbilateral knee orthoses (L1833), lumbar-sacral orthosis (L0650) and suspension sleeves (L2397) provided to the enrollee on September 16, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve a referral.You asked the Planto pre-approve the referral. You say that this is medically necessary.The Plandenied your request. The Plansaysthe provider must be eligible to participate in Medicare.Medicare rules say that Medicare rules say that services must be providedby providers who are enrolled in the Medicare program.The requested provider in this case is not a Medicare-participating 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.