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

We decided that the Plan does not have to waive the copayment for a cystourethroscopy provided on January 7, 2020.
You asked the Plan to waive the copayment for a cystourethroscopy. You say that you keep receiving bills and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for outpatient surgery, including services provided at hospital facilities and ambulatory surgical centers. You have been asked to pay a $100 copayment for a cystourethroscopy. A cystourethroscopy falls within the outpatient surgery, including services provided at hospital facilities and ambulatory surgical centers 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 a cystourethroscopy provided on January 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on February 19, 2020.
You asked the Plan to pay for the assembly and operation of a pump. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating room through the length of the procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the assembly and operation of a pump have not been met. Specifically, payment for this service is included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on February 19, 2020.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.
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. The
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient does not require treatment in an
intensive rehabilitation therapy program. There is concern that the patient would not be able to fully participate
in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility.
Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.
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 for the enrollee..
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve19 additional physical therapy visits.You asked the Plan to pre-approve the additional visits. The Plan denied your request. The Plan says additional visits are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that 19 more therapy sessions are excessive and are generally not accepted as specific and effective therapy for the enrollee's condition without evidence of significant objective functional improvement from prior therapy, which is not evident in the documentation. The enrollee has been instructed in a home exercise program and should be versed in a home exercise program at this point. The documentation indicates that he was intermittently compliant with this home exercise program during a break from therapy. He does not need the unique skills of a professional therapist to safely and effectively provide treatment. The services do not only need to be safely and effectively performed by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 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 additional visits have not been met.Therefore, we decided that the Plan does not have to pre-approve19 additional physical therapy visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you required moderate assistance with bed mobility and transfers. You required supervision to negotiate your wheelchair 100 feet. You tolerated a modified diet and thin liquids. The documentation does not support that you require the specialized skills, knowledge, or judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis, at a SNF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continued CPAP and humidifier rental.
You asked the Plan to pre-approve the continued CPAP and humidifier rental. You say that the enrollee needs
the CPAP. The Plan denied your request. The Plan says the records show the enrollee is not compliant with the
CPAP usage.
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. The Compliance Report shows the enrollee does not meet the criteria
for continuation of the CPAP rental. Based on this information, we decided that Medicare rules for coverage of
the continued CPAP and humidifier rental have not been met. Therefore, we decided that the Plan does not
have to pre-approve the continued CPAP and humidifier rental.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe bile system scan provided on October 22, 2019.You asked the Plan to waive the copayment forthe bile system scan. You say that you have never had a copayment in the past. You also say you were told you would pay one thing but was charged differently. 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 all other diagnostic procedures and tests. You have been asked to pay a $225 copayment for the bile system scan. The bile system scan 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 bile system scan provided on October 22, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that this would benefit the enrollee's
quality of life. The Plan denied your request. The Plan says that this is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6549.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSynvisc (J7325).You asked the Plan to pre-approveSynvisc. You say that the requested medication is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been 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 if the Plan was correct in denying the request to pre-approve Synvisc. Our reviewer says that the medication is not medically necessary. Our physician reviewer found theprovided medical records do indicate prior trial of Orthovisc but the records do not indicate that Monovisc would likely be less effective and/or likely have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met.Therefore, we decided that the Plan does not have to pre-approveSynvisc (J7325).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe core buildup, including any pins when required (D2950).You asked the Plan to pre-approvethe core buildup. You say that the enrollee does not have 8 posterior teeth meeting on occlusal.The Plan denied your request. The Plan says this service is not a covered benefit.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 pre-approvethe core buildup, including any pins when required (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2394) provided on March 10, 2020.
You asked the Plan to pay for the resin-based composite. You say that fillings are covered under your plan. You also say that you should be reimbursed the amount the Plan would have paid for a silver filling. The Plan denied your request. The Plan says this service is not covered under your contract under any normal circumstances. The Plan also says that you are not enrolled in the optional dental benefit 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 resin-based composite (D2394) provided on March 10, 2020.
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 you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rulesto 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 were medically stable. The documentation supports that you required minimal assistance with bed mobility and toilet transfers. You required contact guard to minimal assistance with transfers. You required contact guard assistance with walking 45 feet with a platform rolling walker. The documentation does not support evidence of for supervision by physical medicine and rehabilitation Physician or needs acute rehab nursing care. While you may benefit from further physical therapy and occupational therapy, you do not require an intensive rehabilitation therapy program. Your care needs can be met at a lower level of care.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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Aimovig Autoinjector.
You asked the Plan to pre-approve Aimovig. You say that the drug is medically necessary. The Plan denied your request. The Plan says coverage for this drug is not available under the Part B medical benefit.
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 an Aimovig Autoinjector.
Benefits for Aimovig 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: Drugs
Decision: Favorable

We decided that the Plan has topre-approveRituxan.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says that the services are not medically necessary.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 states that the services are not medically necessary; however, the Plan has not provided any medical records for review. Without medical records, a determination based on medical necessity cannot be supported. Therefore, we decided that the Plan has to pre-approveRituxan.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp for the enrollee.
You asked the Plan to pre-approve Aranesp. You say that this is needed for the treatment of the enrollee's anemia. The Plan denied your request. The Plan says that this is not a supported use.
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 Aranesp. Our reviewer says that Aranesp is not medically reasonable and necessary for the enrollee in this case. Aranesp is not FDA approved for any of the enrollee's diagnoses. The drug is not supported by any of the CMS approved compendia. There were no supporting citations submitted. There are no supporting citations in a PubMed search. The use is not listed as not indicated, not supported or not recommended in any of the compendia. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Aranesp. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide Medtronic Guardian sensors.
You asked the Plan to provide sensors for use with an interstitial continuous glucose monitor (A9276). You say that you need the sensors as they work with your insulin pump. The Plan denied your request. The Plan says this code is not used to bill for supplies used with a covered therapeutic continuous glucose monitor.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The sensors are for a non-covered CGM. Based on this information, we decided that Medicare rules for coverage of sensors for use with an interstitial continuous glucose monitor (A9276) have not been met. Therefore, we decided that the Plan does not have to provide Medtronic Guardian sensors.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the semi-electric hospital bed (E0261) and dry pressure mattress (E0184).
You asked the Plan to pre-approve the semi-electric hospital bed and dry pressure mattress. You say that you feel that the services should be covered by the plan because the enrollee has type 2 diabetes with a skin ulcer. The Plan denied your request. The Plan says the semi-electric hospital bed and dry pressure mattress is not reasonable and necessary.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 semi-electric hospital bed and dry pressure mattress. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not indicate the enrollee's condition requires positioning of the body in ways not feasible in an ordinary bed. The enrollee does not require frequent changes in body position. There is no need for immediate changes in body position. The enrollee's condition does not require special attachments that cannot be fixed and used on an ordinary bed.
The documentation also does not indicate the enrollee is completely immobile, cannot independently make changes in body position significant enough to alleviate pressure, or has any stage pressure ulcer on the trunk or pelvis. A semi-electric hospital bed and a dry pressure mattress is 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 semi-electric hospital bed and dry pressure mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve the semi-electric hospital bed (E0261) and dry pressure mattress (E0184).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontist services.
You asked the Plan to pre-approve endodontist services. You say that you would like the plan to reconsider
their denial The Plan denied your request. The Plan says the requested services are not a covered benefit.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve endodontist services