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

We decided that the Plan does not have to pre-approve OneTouch Ultra Blue test strips.You asked the Plan to pre-approvethe non-preferred brand of test strips. You say that the enrollee uses a OneTouch monitor. The Plan denied your request. The Plan says a non-preferred meter and test strips must be deemed medically necessary for the member by a healthcare provider.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 looked at the file and Medicare rules. There is no documentation that the non-preferred brand is necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of test strips have not been met.Therefore, we decided that the Plan does not have to pre-approveOneTouch Ultra Blue test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 27, 2019 by an out of network (OON) provider.
You asked the Plan to pay for office service. You say that authorization was obtained for this procedure by the surgeon's office. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the referring provider is also out-of-network with the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on September 27, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 4, 2019 by an out of network (OON)provider.You asked the Plan to pay forthe out-of-network services. You say that the clinical documentation demonstrates medical necessity.The Plan denied your request. The Plan says prior authorization was not obtained as required under the plan benefits.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 out-of-network services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on October 4, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approveF5 gene testing (81241).You asked the Plan to pre-approveF5 gene testing. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the requested genetic testing is considered 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. Medicare says CPT Code 81241 for F5 gene testing is not considered to be clinically efficacious and is not medically necessary.Therefore, we decided that the Plan does not have to pre-approveF5 gene testing (81241)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Metaxalone.You asked the Plan to pre-approvethese 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 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-approveMetaxalone.Benefits for these servicesmay be available under Medicare Part D.Contactthe 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 pay for ambulatory continuous glucose monitoring (95250) provided on October 23, 2019.You asked the Plan to pay for the ambulatory continuous glucose monitoring. You say that you would like reconsideration because the provider had to place the monitor back on the member as no data was able to be collected at the time of the visit. The Plan denied your request. The Plan says 95250 will only be reimbursed once per month for the same member, for services provided by the same group physician and/or other Qualified Health Care Professional.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 95250 is not supported in the record. Specifically, CPT code 95920 is only to be reported once per month. The record indicates that this code has already been reported and paid for the same member and provider for date of service October 9, 2019. Based on this information, we decided that Medicare rules for coverage of the ambulatory continuous glucose monitoring have not been met. Therefore, we decided that the Plan does not have to pay for ambulatory continuous glucose monitoring (95250) provided on October 23, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for anesthesia for an endoscopic procedure provided on October 7, 2019.You asked the Plan to waive the deductible foranesthesia. You say that this was for a preventive screening. You say that you were under the impression it was fully covered.The Plan denied your request. The Plan says the deductible applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $750. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services.The item or service you asked the Plan to waive the deductible for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible applies to outpatient surgery services. This cost sharing is a contractual obligation that had not been met at the time anesthesia was received on October 7, 2019.Therefore, we decided that the Plan does not have to waive the deductible foranesthesia for an endoscopic procedure provided on October 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea FreeStyle Libre Continuous Glucose Monitoring (CGM) system.You asked the Plan to pre-approvea CGM. You say that you check blood sugar levels four times a day.The Plan denied your request. The Plan says the medical record shows you were instructed to test before meals.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 looked at the file and Medicare rules. There is no log,in the record, of testing. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met.Therefore, we decided that the Plan does not have to pre-approvea FreeStyle Libre Continuous Glucose Monitoring (CGM) system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for crowns (D2751) for teeth 25 and 26 provided October 8, 2019.You asked the Plan to pay for the crowns. You say that you required the crowns and is paying out of pocket for them The Plan denied your request. The Plan says these services are not covered to restore a tooth that is worn away. The records submitted do not show that you meet the criteria 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 crowns 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 pay for the crowns. Our reviewer says that this enrollee does not meet the criteria. Our physician reviewer found teeth number's 25 and 26 do not appear to have significant breakdown due to caries or fracture to meet the criteria for crown restorations.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 crowns have not been met.Therefore, we decided that the Plan does not have to pay for crowns (D2751) for teeth25 and 26 provided October 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefacet joint radiofrequency ablation for the enrollee.You asked the Plan to pre-approvethe injection. Yousay that this is medically necessary.The Plan denied your request. The Plan says the enrollee would not be eligible for a repeat injection until 8/5/20.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 injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the issue is over-utilization. The criteria limits RFA to 4 joints or 2 levels bilaterally. The request is for a total of six levels in two sessions. Further, the utilization is limited to 2 sessions in a rolling 12 month period. Therefore, the requested procedure is deemed not medically or reasonable.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 injection have not been met.Therefore, we decided that the Plan does not have to pre-approvefacet joint radiofrequency ablation for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that your orthotics are over 40 years old and you
cannot afford new ones. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate forthe complete series of periapical x-rays (D0210) provided on December 6, 2019.You asked the Plan to pay the in network rate forthe complete series of periapical x-rays. You say that you received bitewing x-rays. You say that per the dental provider directory, the dental office in this case was listed. You also say that you were not told that the specific provider you were seeing was not in network with the Plan.The Plan denied your request. The Plan says periapical x-rays are not listed as a covered service.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, periapical x-rays are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay the in network rate forthe complete series of periapical x-rays (D0210) provided on December 6, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility services.
You asked the Plan to pay for the SNF services. You say that had you been informed that the plan was not
going to cover the services you would not have taken him out of the hospital. You thought the benefits would
start all over again since it's a new year. The Plan denied your request. The Plan says the 100 SNF day benefit
has been exhausted.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.
The file shows that you received 100 days of SNF care during the benefit period from March 27, 2019 -
September 15, 2019. The Plan has covered 100 days of SNF care.
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
coverage during this benefit period. You will be eligible for a new benefit period when you have not been
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the
Plan does not have to pay for skilled nursing facility services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you were not aware that you needed prior authorization. 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on July 5, 2019 by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.You asked the Plan to pre-approvethese services. You say that the services are medically necessary.The Plan denied your request. The Plan says the step therapy requirement is not met.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 ifthe 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 diagnoses of other specified disorders of bone density and structure,Vitamin D deficiency, and other osteoporosis with current pathological fracture of the left femur. She has not tried and failed the plan's required drug of oral bisphosphonates. The records do not show that the required drug would be less effective or contraindicated; therefore, Prolia is not reasonable or medically necessary 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 not been met.Therefore, we decided that the Plan does not have to pre-approveProlia.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for CT scan provided on June 8, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that there was no reason to do the CT scan and you will not pay the copayment. 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 a $225 copayment for each in-network Medicare-covered advanced imaging service (not including x-rays). You have been asked to pay a $225 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you received the CT scan.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the CT scan provided on June 8, 2019.
Your complaint about the hospital charging more due to new construction is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on April 1, 2019.You asked the Plan to waive the copayment forthe specialist office visit. You say that you should not be responsible for the copayment. The Plandenied 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 a $25 copayment for each visit to a contracted specialist for Medicare-covered services. This includes visits to a nurse or physician assistant. You have been asked to pay a $25 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. Thiscost 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 specialist office visit provided on April 1, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay foremergency care services provided from May 20, 2019 to May 23, 2019.You asked the Plan to pay foremergency care. You say that the enrollee wastravelling outside of the Plan's service area while pregnant.The Plan denied your request. The Plan says that the denial of payment for these services is correct, because these providers are out-of-network with the Plan and prior authorization was not obtained.The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be such that a prudent laypersonwith an average knowledge of medicine would reasonably expect the absence of immediate medical attention would result in serious jeopardy to their health. We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical care to seriously jeopardize their health in this case.Therefore, we decided that the Plan has to pay foremergency care services provided from May 20, 2019 to May 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous blood glucose monitoring system.
You asked the Plan to pre-approve a Dexcom G6 continuous blood glucose monitoring system. You say that your fingers are sore and you do not want to check levels while at work. The Plan denied your request. The Plan says documentation indicating dose adjustments was not provided and could not be determined via your medication fill history.
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 looked at the file and Medicare rules. The medical records do not support frequent adjustment of the insulin regimen. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 continuous blood glucose monitoring system have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous blood glucose monitoring system.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs device (C2624, 33289).
You asked the Plan to pre-approve a CardioMEMs device. You say that the service is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a CardioMEMs device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CardioMEMs device have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMs device (C2624, 33289).