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

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM)
and supplies.
You asked the Plan to pre-approve a CGM and supplies. You say that this device will help ease the extremely
soreness on the fingers from the multiple times you have to prick them on a daily routine. The Plan denied your
request. The Plan says that you do not use insulin.
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 use insulin
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre
continuous glucose monitor (CGM) and supplies.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the hip for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your
request. The Plan says the criteria require abnormal labs or other test results.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
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 the scan. Our reviewer says that the
requested imaging is not medically reasonable or necessary. Our physician reviewer found that in this case, the
record indicates that the enrollee has erosive osteoarthritis and osteopenia shown by imaging. The provided
records do not indicate any acute or changed circumstances from the enrollee's baseline status. The medical
necessity and reasonableness of the requested service is not established by the records submitted. The elements
of the coverage criteria are not satisfied.
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 scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve CT scan of the hip for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an out of area cardiology check up for a device.
You asked the Plan to pay this claim. You say that this check-up should be paid by the Plan. The Plan denied your request. The Plan says these were out of area services for a known condition. The enrollee had a device implanted in 2020. The enrollee was told to have a checkup and three-day device monitoring a year later. The device checkup and monitoring could have been provided in network. The Plan also notes out of area services had previously been denied to the enrollee prior to the date of service.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.
This was a checkup and evaluation for services provided a year ago. The enrollee self-referred and was aware the Plan denied this request. Based on this information, we decided that Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for an out of area cardiology check up for a device.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve a belatacept injection, 1 mg.
You asked the Plan to pre-approve the belatacept injection. You say that the enrollee has been on this drug for the past year. You also say that it was previously approved. The Plan denied your request. The Plan says that the requested use of this drug is not approved by the Food and Drug Administration (FDA).
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 the belatacept injection. Our reviewer says that the requested belatacept injection is medically necessary. Our physician reviewer found belatacept is not approved for the enrollee's diagnosis. However, the reviewer found that clinical research supports that belatacept can be an effective alternative immunosuppressive agent in heart transplant recipients in order to preserve renal function. The reviewer found that with careful monitoring, the safety profile of belatacept injection has been shown to be acceptable. The reviewer also found that the documentation support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. Therefore, the reviewer found that the requested belatacept injection is 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 belatacept injection have been met. Therefore, we decided that the Plan has to pre-approve a belatacept injection, 1 mg.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray of the hand (73130) provided on March 4, 2021.
You asked the Plan to waive the copayment for an x-ray of the hand. You say that you never received an x-ray of the hand and it was only an office visit. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 copayment for outpatient diagnostic tests and therapeutic services and supplies including an x-ray of the hand.
You have been asked to pay a $35 copayment for an x-ray of the hand. The records show that an x-ray of the hand was performed by the provider. The EOC confirms a $35 copayment is the required copayment for this service. You have been asked to pay a copayment of $33.77, which is less than the Plan's contracted amount. An x-ray of the hand 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 for an x-ray of the hand (73130) provided on March 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (88305, 88312) rendered by the out of network (OON) provider on February 8, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial of payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 the laboratory services (88305, 88312) rendered by the out of network (OON) provider on February 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider
from October 28, 2020, to February 5, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 had network providers
available who could have provided the services at issue in this appeal. 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 the services provided to you by an out-of-network provider from
October 28, 2020, to February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on October 21, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 physician services provided on October 21, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on February 5, 2021, to February 9, 2021 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that these services are required before moving to a new facility. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained.
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 had network providers available who could have provided 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 work provided on February 5, 2021, to February 9, 2021 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

You asked the Plan to pay for acute inpatient hospital care. You say the inpatient hospital care was medically necessary. The Plan denied your request. The Plan says this request does not meet criteria for inpatient stay as services could have been rendered in another setting.
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 that the enrollee was a then, a 43-year-old male who had a diagnosis of acute alcohol abuse. On September 18, 2020 he presented to the hospital seeking assistance for alcohol withdrawal. The enrollee reported drinking 2 pints of vodka a day for 6 months with his last drink being on September 16, 2020. Upon admission he denied suicidal/homicidal ideation, nausea, vomiting, diarrhea, constipation, and abdominal pain. He was hemodynamically stable. He reported a good appetite with appropriate water intake, denied chest pain and/or shortness of breath, headache, or blurred vision. The enrollee denied a new onset of cough, fever, chills, body aches, urinary urgency, or frequency. The clinical documentation provided reported during admission assessment that the enrollee did not have any signs and symptoms of detox present, screened negative for substances and was safe to be discharged home. The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that enrollee's necessary hospital care (including earlier emergency department and/or observation 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 from September 18, 2020, through September 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs you received from December 16, 2020, to December 30, 2020.
You asked the Plan to waive the coinsurance for the chemotherapy drugs. You say that you believe you had met your out-of-pocket maximum prior to receiving these drugs, so you shouldn't have to pay coinsurance. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for Medicare Part B drugs.
You have been asked to pay 20% coinsurance for the chemotherapy drugs. The chemotherapy drugs fall within the Medicare Part B drugs benefit category. The records show that you had not met your out-of-pocket maximum for 2020 until after these services were rendered. 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 chemotherapy drugs you received from December 16, 2020, to December 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visit (99213) to be provided by an
OON provider.
You asked the Plan to pre-approve the office visit. You say that the doctor is a participating provider, and you
are appealing the denial for chiropractic services. The Plan denied your request. The Plan says enrollee's must
receive their medical services from an in-network provider with the exception being urgent or emergent
services. Non-emergent services with non-contracted providers require prior authorization before services
being rendered.
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 outpatient office visit (99213) to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and supplies.
You asked the Plan to pre-approve a CGM and supplies. You say that this is medically necessary. The Plan denied your request. The Plan says criteria for coverage have 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 you do not use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.
Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implantable auricular stimulator.
You asked the Plan to pre-approve an implantable auricular stimulator. You say that this device is covered by Medicare. The Plan denied your request. The Plan says implantable auricular stimulators are not covered by the Plan or Medicare.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We looked at this the file and Medicare rules. Medicare does not cover auricular stimulation. Based on this information, we decided that Medicare rules for coverage of an implantable auricular stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an implantable auricular stimulator.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation (A0120).
You asked the Plan to pre-approve the additional routine transportation. You say that you need the additional
rides for future appointments. The Plan denied your request. The Plan says your benefit only allows 24 trips for
this service. The Plan also says that you have taken a total of 23 trips since January 25, 2021, and have 1 trip
remaining.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 24 one-way trips per year.
We looked at your request, the records in the case file, and the rules. The record shows that you have taken a
total of 23 trips since January 25, 2021, and have 1 trip remaining. Based on this information, we decided that
you will have exhausted the Plan maximum benefit for coverage of routine transportation after you take the 1
remaining trip. Therefore, we decided that the Plan does not have to pre-approve additional routine
transportation (A0120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an DyAnsys electro-acupuncture device coded as 64555
and L8679.
You asked the Plan to pre-approve an electro-acupuncture device. You say that the enrollee has tried and failed
conservative care and medication therapies. Based on his history and current diagnoses, the provider is
recommending the neurostimulator to decrease pain. The Plan denied your request. The Plan says the requested
electro-acupuncture device is not covered by Medicare.
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 an electro-acupuncture device have not been met. Therefore, we decided that the Plan does not
have to pre-approve an DyAnsys electro-acupuncture device coded as 64555 and L8679.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implant placement (D6010) for teeth # 6, 18, 19, 30, and 31.
You asked the Plan to pre-approve the dental services. You say that You say that you need these implants. You also say that it hurts really bad, and it grinds. The Plan denied your request. The Plan says The Plan says that the implant placements are not medically necessary. The Plan also says there may be other treatment options for your dentist to replace your missing teeth.
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, implants are not covered when more than 1 tooth is missing in an arch. Therefore, we decided that the Plan does not have to pre-approve implant placement (D6010) for teeth # 6, 18, 19, 30, and 31.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on May 29, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because molecular genetic hereditary predictive screening testing is not a Medicare 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 test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic testing provided on May 29, 2020.