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

We decided that the Plan does not have to pay for ambulance services provided on July 22, 2019.
You asked the Plan to pay for the ambulance services. You say that the enrollee's hospice election ended on July 14, 2019. The Plan denied your request. The Plan says The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on July 14, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services provided on July 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on July 18, 2019.You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says you must purchase hearing aids through a network provider to receive coverage.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided from a network hearing service provider.We looked at the file and the Plan's rules. The file shows the hearing aids were not provided by a network hearing aid service provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met.Therefore, we decided that the Plan does not have to reimburse you forhearing aids provided on July 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the upper endoscopy provided on October 7, 2019.
You asked the Plan to waive the copayment for the upper endoscopy. You say that you do not understand why you have to pay a $400 copayment. You say you were hospitalized on July 2, 2019 and they cauterized the bleeding ulcer and had a follow-up appointment on July 7, 2019. 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 $400 copayment per visit for in-network outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $400 copayment for the upper endoscopy. The upper endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient 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 the upper endoscopy provided on October 7, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve Entyvio (vedolizumab) injections.You asked the Plan to pre-approve the Entyvio. You say that this is a necessary treatment.The Plan denied your request. The Plan saysthere has been no trial of Stelara, which is required priorto coverage of Entyvio. There is no medical reason that Stelara would be less effective.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 the Entyvio. Our reviewer says that the requested drug is not medically necessary based on step therapy rules. Our physician reviewer found the enrollee is a 74-year-old woman with a diagnosis of Crohn's disease of the large intestine without complications. The enrollee has not trialed the preferred step therapy drug. The documentation does not support that Stelara would likely be less effective and/or likely have adverse effects for theenrollee in this case.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 Entyvio have not been met.Therefore, we decided that the Plandoes not haveto pre-approveEntyvio (vedolizumab) injections.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hip arthroscopy with femoroplasty and labral repair.
You asked the Plan to pre-approve the hip surgery. You say that this surgery is necessary to improve function and reduce pain. The Plan denied your request. The Plan says there is no evidence that the injections given did not work and she has not tried a full course of physical therapy.
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 hip surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not clearly show that the patient has tried and failed conservative measures to include PT. There are no red flags for surgery. Surgery is not needed 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 the hip surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve hip arthroscopy with femoroplasty and labral repair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the walk-in shower (E1399).
You asked the Plan to pre-approve the walk-in shower. You say that this will make life easier and safer. It is very hard to take a shower by yourself and feel comfortable. This will also improve your quality of life. The Plan denied your request. The Plan says this item is non-covered as this is a convenience item and not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the walk-in shower (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral periapical x-ray (D0220) provided on September 30, 2019.
You asked the Plan to pay for the dental service. You say that the x-ray was necessary to see how deep the removal of your tooth would be and to not disrupt the tooth next to it. The Plan denied your request. The Plan says periapical x-rays are excluded from coverage.
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 periapical x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral periapical x-ray (D0220) provided on September 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC) with multiple power options for the enrollee
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 the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a Group 2 PWC 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 not medically necessary. Our physician reviewer found the records do not show that the enrollee's upper extremity strength and full range of motion do not support that they are unable to to perform a functional weight shift. There is no evidence of any conditions that would require the Group 2 PWC. The requested PWC 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-approve a Group 2 power wheelchair (PWC) with multiple power options for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 140mg Repatha Sureclick (C9399).

You asked the Plan to pre-approve the Repatha. You say that you would like reconsideration based on the records submitted as the member has tried other drugs and experienced negative side effects. The Plan denied your request. The Plan says this drug is not covered under the member's Medicare Part B 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 140mg Repatha Sureclick (C9399). 

Benefits for the Repatha 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder, elbow, wrist hand orthotic (SEWHO) provided on May 24, 2019.You asked the Plan to pay for the SEWHO. You say that please see the included documentation that clearly shows the items were dispensed and received by the enrollee on May 31, 2019. The Plan denied your request. The Plan says there is no commensurate note in the medical records on or around the date as to why the brace was being ordered.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SEWHO. 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 support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is insufficient documentation of a physical examination of the shoulder, and the need for a shoulder/arm orthosis.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 SEWHO have not been met.Therefore, we decided that the Plan does not have to pay for the shoulder, elbow, wrist hand orthotic (SEWHO) provided on May 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that you feel you are not ready to go home and still need care. The Plan denied your request. The Plan says the denial of authorization for inpatient hospital care is correct, because you no longer need inpatient hospital care and are stable for discharge to a lower level of care.
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 pre-approve 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 as of January 28, 2020 you were not being treated for an acute condition to warrant acute inpatient hospital care. Plans for discharge to a lower level of care were documented appropriately. Therefore, the records show that the admitting physician reasonable expected that your necessary hospital care would not span at least 2 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 pre-approve acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forchiropractic services provided by an out-of-network provider, on June 17, 2019 to August 5, 2019.You asked the Plan to pay forchiropractic services. You say that you are asking for the Plan to reconsider this payment.The Plandenied your request. The Plan says there is no out-of-network coverage for these services.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Yourcontract with the Plan clearly says that you must pay 100% for this service because there is no out-of-network coverage for chiropractic services/out-of-network. You have been asked to pay 100% for out-of-network chiropractic services. Chiropractic services fall within the chiropractic services/out-of-network 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 pay forchiropractic services provided by an out-of-network provider, on June 17, 2019 to August 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the drugs or medicaments (D9630 x 3) provided on August 22, 2019.
You asked the Plan to pay for the 3 drugs or medicaments. You say that you received a letter advising the tooth extractions would be covered. The Plan denied your request. The Plan says drugs or medicaments is 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, drugs or medicaments is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the drugs or medicaments (D9630 x 3) provided on August 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rinvoq 15mg ER tablets.
You asked the Plan to pre-approve the Rinvoq tablets. You say that this is necessary for the enrollee's condition. The Plan denied your request. The Plan says this oral drug is not covered by Medicare Part B.
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 Rinvoq 15mg ER tablets.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will require another 3-4 weeks to transition from his acute illness. The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current acute care facility.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for congested heart failure and an acute kidney injury. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plan denied your request. The Plansays there is no objective evidence of unstable conditions requiring the inpatient level of care.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 fileand 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. Ourphysician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee does not require this on an intensive rehabilitation facility therapy program level in an IRF.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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies coded as A4253, A4259, A4256 and A4235 provided by HNC Medical Supplies LLC on August 9, 2019.
You asked the Plan to pay for the diabetic supplies. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the service so that the Medicare coverage criteria has been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order and delivery ticket submitted did not include the carrier's tracking number, nor did the proof of delivery include an order number or details to corroborate the delivery ticket submitted. Therefore, we decided that the Plan does not have to pay for the diabetic supplies coded as A4253, A4259, A4256 and A4235 provided by HNC Medical Supplies LLC on August 9, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One (J7326).
You asked the Plan to pre-approve Gel-One. You say that you have severe pain and would like to avoid surgery. The Plan denied your request. The Plan says the enrollee has not tried and failed Orthovisc as required by step therapy rules.
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 Gel-One. Our reviewer says that criteria for coverage of Gel-One have not been met. Our physician reviewer found the Plan requires a trial of drug Orthovisc first before they will approve the requested drug, Gel-One. The provided medical records do not indicate that the patient has tried and failed the required drug or that the Plan's required drug would likely be less effective or 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 Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One (J7326).
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 the enrollee needs rehab. The Plan denied your request. The Plan says the services are 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 rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was hospitalized on January 22, 2020 after a fall with resulting left hip fracture. She underwent surgical treatment of the fracture. The progress note dated January 27, 2020 states the pain is controlled and she has been out of bed and has no chest pain or shortness of breath. She has no complex medical, nursing, or rehabilitation issues that require the intensity of an IRF stay with close physician or nursing supervision. She may benefit from further therapy but does not require an intensive therapy program in an IRF. 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.