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

We decided that the Plan does not have to pre-approve continued care with an out-of-network tertiary level oncologist.
You asked the Plan to pre-approve continued care with an out-of-network tertiary level oncologist. You say that the requested continued care with a tertiary level oncologist is medically necessary. The Plan denied your request. The Plan says the requested continued care with a tertiary level oncologist is not medically necessary.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 continued care with an out-of-network tertiary level oncologist. Our reviewer says that the requested continued care with a tertiary level oncologist is not medically necessary. Our physician reviewer found the enrollee has a personal history of malignant melanoma of skin and follow's up with hematology/oncology once every 6 months for continued surveillance.
Based on the documentation provided, the plan's denial is medically justified on the basis that it is offering adequate care to meet the enrollee's medical needs through referral. There is nothing unique about the enrollee's condition that would make it medically necessary to see the requested out-of-network, tertiary level provider. The Plan has shown that they have in-network providers who meet the Standards of Care required for treatment of the enrollee's condition. Continued care with a tertiary level oncologist is not medically reasonable and necessary for the enrollee in this case as the enrollee can safely transition to an in-network non-tertiary provider. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued care with an out-of-network tertiary level oncologist have not been met. Therefore, we decided that the Plan does not have to pre-approve continued care with an out-of-network tertiary level oncologist.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a full night titration study.You asked the Plan to pre-approve the study. You say that this is medically necessary.The Plan denied your request. The Plan says titration can be done at home using an auto-titrating PAP(APAP) machine.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 study. Our reviewer says that the requested study is not considered medically reasonable and necessary in this case. Our physician reviewer found an attended, in-lab PSG for PAP titration is considered not medically necessary. The accepted standard of care in thissituation is a trial of auto-titrating CPAP (APAP) at home. This patient has no contraindications for this, such as severe heart failure or lung disease. If APAP is not successful in treating the sleep-disordered breathing, then an attended PAP titration study may become 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 study have not been met.Therefore, we decided that the Plan does not have to pre-approve a full night titration study.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia at a lower cost (tier exception).
You asked the Plan to pre-approve Prolia at a lower cost. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says tier exceptions only apply to Part D drugs.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for Medicare Part B prescription drugs. We looked at the file, the Plan's contract and Medicare rules. In this case, you are requesting a tier exception for Prolia. Medicare says that tier exceptions only apply to Part D drugs. Under Medicare rules, your request is not covered for a tier exception because Prolia is not covered under Medicare Part D. This drug is covered under your Medicare Part B (medical) benefit. Therefore, we decided that the Plan does not have to pre-approve Prolia at a lower cost (tier exception).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a Libre Continuous Glucose Monitor (CGM).
You asked the Plan to pre-approve the Libre Continuous Glucose Monitor (CGM). You say that the enrollee is taking Lantus once daily and Humalog before each meal to control her Type 2 Diabetes. You say that the enrollee checks her glucose 4-6 times per day and meets the criteria or coverage. The Plan denied your request. The Plan says that the enrollee does not test their glucose at least 4 times per day. The Plan says that there is no evidence that the enrollee receives at least 3 insulin injections per day. The Plan says that the enrollee is not on a continuous insulin infusion pump.
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 the Libre Continuous Glucose Monitor (CGM).. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee has been prescribed a regimen of 4 insulin shots per day. The enrollee should be and, according to her doctor's note, is checking her blood glucose levels 4 times a day to help improve her control. The requested CGM will help the enrollee adjust her insulin doses daily at meals. 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 Libre Continuous Glucose Monitor (CGM). have been met. Therefore, we decided that the Plan has to pre-approve a Libre Continuous Glucose Monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says self-administered drugs are not covered.
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 Entresto.
Benefits for these services 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested admission to an IRF does not meet criteria. Our physician reviewer found thecomplexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status does not require intensive physician and nursing oversight that is present in an IRF. The enrollee may benefit from additional multiple therapies, however the documentation does not support that the enrollee's functional level requires this on an IRF level.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental surgery procedure provided on October 8, 2019.
You asked the Plan to pay for the dental surgery procedure. You say that the services were provided by a
subject matter expert, the charges are legitimate, and deserves to be paid in full. The Plan denied your request.
The Plan says charges this service is not covered under the enrollee's plan.
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 requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental
surgery procedure provided on October 8, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an epidural steroid injection (ESI).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.The Plan must follow Medicare rules. Medicare rules say that an ESI is covered when specific criteria are met.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 chronic low back pain with L5/S1 radiculopathy. She has herniated discs on magnetic resonance imaging (MRI). She has had physical therapy and chiropractic therapy. She had a good result from a prior ESI that lasted three weeks. The enrollee meets the criteria for coverage of an ESI and the injection is reasonable and medically necessary for the enrollee 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 been met.Therefore, we decided that the Plan has to pre-approve an epidural steroid injection (ESI). 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pontic for tooth #30.
You asked the Plan to pre-approve the pontic. The Plan denied your request. The Plan says the service is not medically necessary.
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 pontic 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 pontic. Our reviewer says that the service is not medically necessary. Our physician reviewer found if two implant crowns are placed in area 30 and 31 to replace the missing teeth, a pontic is 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 pontic have not been met. Therefore, we decided that the Plan does not have to pre-approve the pontic for tooth #30.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bronchial thermoplasty for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure is still experimental and investigational.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of severe persistent asthma on maximal medical therapy, including omalizumab. However, pulmonary function testing results are not provided for confirmation of the diagnosis and assessment of severity and reversibility. The clinical trials of this treatment excluded patients with any significant heart disease, and this patient has a history of acute MI and cardiomyopathy. The AIRS2 study excluded patients with OSA, which this patient has. The safety and effectiveness of this treatment in patients with these conditions has not been studied. The results of pulmonary function testing are needed to assess safety (FEV1 60% or better before bronchodilator) and confirm the diagnosis of asthma. Bronchial thermoplasty is therefore considered not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve bronchial thermoplasty for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prosthetic leg accessories (L5781 and L5962) for the enrollee.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says these accessories are 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 the accessories. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that there is an extenuating special need for protection against unusually harsh environmental situations that would require approval of L5962 over the L5704. The L5761 is not considered medically reasonable and necessary as it appears to exceed the enrollee's medical need as he has no evidence of excessive edema or swelling in the residual limb that would require this requested residual limb volume management system. 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve prosthetic leg accessories (L5781 and L5962) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for canaloplasty surgery provided on October 23, 2019.
You asked the Plan to pay for canaloplasty. You say that this is the correct code for the procedure, and you have submitted medical records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the effectiveness of this procedure has not been established.
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 canaloplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records and the data from medical literature, treatment with canaloplasty surgery is not likely to be more beneficial than the current available treatments for the enrollee's condition. Records show no indication that canaloplasty would offer better treatment than standard surgical treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of canaloplasty have not been met. Therefore, we decided that the Plan does not have to pay for canaloplasty surgery provided on October 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat diagnostic medial branch block (MBB).
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 the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MBBs are covered when specific criteria are met. 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 enrollee has chronic low back pain. The magnetic resonance imaging (MRI) on October 30, 2019 showed multi-level spondylosis and foraminal narrowing. He underwent diagnostic MBBs and stated at the next visit that they did not help. The diagnostic block was therefore negative and should not be repeated. The repeat MBB is not reasonable or 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 not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat diagnostic medial branch block (MBB).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that you are diabetic and on the date of service you were working outdoors when you became aware that your blood sugar was getting low. You became confused and were unable to get help. Your wife found you incoherent and unresponsive so she called911. The EMS responders treated you, raising your blood sugar levels and stayed with you until you were stable. You say that they wanted to transport you to the hospital however since you were functioning again you declined transportation. You say that the treatment and assistance you received prevented the need for a hospitalization.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on December 20, 2018. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve home health services for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that the continued need for skilled nursing care is not documented in the clinical notes submitted.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the medical information supports that the enrollee is homebound due to pain and weakness. Skilled nursing services are medically necessary. The enrollee has poorly controlled pain, and is unable to accurately monitor his diabetes. The enrollee also requires skilled therapy services. He is unable to perform essential activities, such as bed mobility. There is significant upper and lower extremity weakness. Therapy is also indicated for assessing and treating pain, using non-pharmacological means.

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 been met. Therefore, we decided that the Plan has to pre-approve home health services for the enrollee. 

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 waive the coinsurance for the shoulder brace provided on December 12, 2019.You asked the Plan to waive the coinsurance for the shoulder brace. You say that you did not expect a separate bill because everything related to the surgery was included in the bill from the hospital. 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 20% coinsurance for Medicare-covered items and related supplies. You have been asked to pay $10.80 which is 20% of the allowed amount for the shoulder brace. The allowed amount is $54.00. ($54.00 x 20% = $10.80). The shoulder brace falls within the "Durable medical equipment (DME) and related supplies" benefit category. This means that you have been asked to pay the Medicare 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 shoulder brace provided on December 12, 2019.