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

 
We decided that the Plan does not have to waive the coinsurance for the lumbar-thoracic brace provided on 
April 20, 2020. 
 
You asked the Plan to waive the coinsurance for the lumbar-thoracic brace. You say that you are unwilling to 
pay for this brace you were given without any measurements and which you got no benefit. The Plan denied 
your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of 
the monthly cost until the item is deemed a purchase.  
 
You have been asked to pay $288.10 which is 20% of the allowed amount for the lumbar-thoracic brace. The 
allowed amount is $1,440.48. ($1,440.48 x 20% = $288.10). The lumbar-thoracic brace falls within the 
Durable medical equipment (DME) and related 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 coinsurance for the lumbar-thoracic brace provided on April 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Up walker (E1399). 
 
You asked the Plan to pre-approve an Up walker. You say that the item is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a standard walker (E0130, E0135, E0141, E0143) and 
related accessories are covered if specific criteria is 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 an Up walker. Our reviewer says that 
the item is not medically necessary. Our physician reviewer found the documentation does not reveal that the 
enrollee requires an UpWalker. The documentation indicates the enrollee has a walker already. There is no 
evidence that the enrollee is unable to participate in one or more mobility-related activities of daily living 
(MRADLs) with her current walker. There is no evidence that her functional mobility cannot be sufficiently 
resolved safely with the use of a standard walker. The request for the UpWalker appears to exceed her medical 
need and 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 an Up walker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Up walker (E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex). 
 
You asked the Plan to pre-approve Vertiflex. You say that you cannot walk and have had several procedures 
that did not work. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because studies have not proven that this device is helpful for treatment of your condition. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this device is experimental. More research is needed to show its safety and efficacy. There is no 
spinal instability. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on 
September 2, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that it is not your fault that 
you had to go to multiple different providers, and feel this should be covered. The Plan denied your request. 
The Plan says benefits for this service are limited to one time per calendar year. 
 
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, emergency diagnostic exam is limited 
to 1 every year. The record shows that you received a problem focused limited oral evaluation on July 22, 
2020, and your emergency diagnostic exam benefit had been exhausted. Therefore, we decided that the Plan 
does not have to pay for the problem focused limited oral evaluation provided on September 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 14 day reader device for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the needed information was not sent. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found Medicare only covers a Continuous Glucose Monitor (CGM) for individuals who test at least four times 
a day with changes to the amount of insulin based on their readings. There needs to a minimum of three 
injections of varying doses of insulin each time or use of an insulin pump for continuous insulin therapy. In this 
case, the record shows that the enrollee is on insulin once a day and he does not change his dose based on blood 
glucose readings. The review indicates that the monitor is considered therapeutic and there is a diagnosis of 
diabetes mellitus. The enrollee has not been using insulin multiple times (3 or more) a day and the treatment 
does not require frequent adjustment on the basis of testing results. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Freestyle Libre 14 day reader device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora laryngoscopy provided on July 16, 2020.You askedthe Plan to waive the copayment fora laryngoscopy. You say that you should only owe a $30 specialist copayment and you do not understand why you are being charged such a high copayment.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 $250 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. The record shows that you received a laryngoscopy on July 16, 2020, at an outpatient hospital facility. A laryngoscopy is considered a surgical procedure. Therefore, you are responsible to pay the $250 copayment. You have been asked to pay a $250 copayment for a laryngoscopy. A laryngoscopy falls within the outpatient surgery and other medical 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 fora laryngoscopy provided on July 16, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedental services (D4210).You asked the Planto pre-approvethe services. You say that the delay of this procedure is impacting your health.The Plandenied your request. The Plansaysthis 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 Plandoes not haveto pre-approvedental services (D4210).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe genetic testing rendered on May 19, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was billed incorrectly.The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479.Therefore, we decided that the Plan does not have to pay forthe genetic testing rendered on May 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing facility services provided from August 1, 2020, to August 30, 2020.You asked the Plan to pay forthe skilled nursing facility services. You say that the Plan should pay this claim.The Plan denied your request. The Plan says the enrollee did not have a need for daily skilled care.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 looked at the fileand Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing facility services have not been met.Therefore, we decided that the Plan does not have to pay forskilled nursing facility services provided from August 1, 2020, to August 30, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675 and E0673) 
provided on July 17, 2020. 
 
You asked the Plan to pay for the pneumatic compression device. You say that you would like reconsideration 
because this device was a medically necessary preventive device used during the member's surgery. The Plan 
denied your request. The Plan says this is not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items that are used for a preventative service or 
function are excluded from coverage under the Medicare DME benefit. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the pneumatic compression device have not been met. Specifically, the record indicates that the 
pneumatic compression device was used for the prevention of deep venous thrombosis prophylaxis during and 
after the member's surgery. Therefore, we decided that the Plan does not have to pay for the pneumatic 
compression device (E0675 and E0673) provided on July 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea below-elbow test socket addition for an arm prosthesis.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the servicesare not covered.The Plan must follow Medicare rules. Medicare rules say that the use of L codes for specific amputation levels near the partial hand level is considered incorrect coding.We looked at the file and Medicare rules. The item at issue is a test socket for a below-elbow prosthesis described by code L6680. The approved prosthesis described by code L6000 is for a partial hand prosthesis. The L6680 socket is not appropriate for approval with this prosthesis.Therefore, we decided that the Plan does not have to pre-approvea below-elbow test socket addition for an arm prosthesis.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLosartan-Hydrochlorothiazide.You asked the Plan to pre-approveLosartan-Hydrochlorothiazide. You say that the medication is necessary.The Plandenied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.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-approveLosartan-Hydrochlorothiazide.Benefits for Losartan-Hydrochlorothiazidemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forlocalized delivery of antimicrobial agents (D4381); periodontal scaling and root planning (D4341); and gingival irrigation -per quadrant (D4921) provided on August 27, 2020.You asked the Plan to pay forlocalized delivery of antimicrobial agents, periodontal scaling and root planningand gingival irrigation -per quadrant. You say that the services should be covered.The Plan denied your request. The Plan says the services are not covered under your 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.Specifically, the services are not listed in the Plan's benefit chart making them non-covered services.Therefore, we decided that the Plan does not have to pay forlocalized delivery of antimicrobial agents (D4381); periodontal scaling and root planning (D4341); and gingival irrigation -per quadrant (D4921) provided on August 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 17, 2019 and 
December 23, 2019 by an out of network provider. 
 
You asked the Plan to pay for the office visit and surgical services. You say that you would like the Plan to pay 
the claims. The Plan denied your request. The Plan says you did not request 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 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 medical services provided on December 17, 2019 and 
December 23, 2019 by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy guidelines were not followed. 
 
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 injection. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the documentation does 
not show a failure of Orthovisc and Monovisc. The above preferred medications would not likely be less 
effective or have more adverse side effects than the requested Synvisc-one medication as these are all in the 
same class of medication and have been shown to have essentially equivalent risk and effectiveness. 
 
 
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-approve Synvisc-One for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda Solution 100MG/4ML (CPT Code J9271). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee does not meet the requirements for this medication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 medication. Our physician reviewer 
found per compendia Keytrda requires microsattelite instability or tumor mutational burden greater than or 
equal to 10. The requirements are not met and there is no compendia or literature to support Keytruda + 
Lenvatanib. 
 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda Solution 100MG/4ML (CPT Code J9271).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are 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. 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.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-approvelong term acute care hospital (LTACH) services
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance ride provided on May 10, 
2020. 
 
You asked the Plan to waive the copayment for the ambulance ride. You say that it was medically necessary to 
be transferred to the qualitied facility to treat your intestinal transplant related issues. 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 $275 
copayment for each covered, one-way ambulance trip by ground or water for in- and out-of-network ambulance 
services. For this date of service, you have been asked to pay the allowed amount of the claim because this 
amount is less than the $275 copayment for the ambulance ride. 
 
You have been asked to pay a $222.54 copayment for the ambulance ride. The ambulance ride falls within the 
Ambulance services 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 
ambulance ride provided on May 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve adjustable height, detachable armrest (CPT Code 
E0973), anti-tipping device (E0971), and heel loop/holder (E0951). 
 
You asked the Plan to pre-approve the DME. You say that the enrollee already has a wheelchair which is too 
large to fit in the doorway of the home. You state that this request is for a smaller wheelchair to help the 
enrollee in getting out of the house. The Plan denied your request. The Plan says the enrollee can self-propel in 
a standard wheelchair and does not require an arm height difference then what is available. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The requested options/accessories (L33792) are covered if the beneficiary has a wheelchair that meets 
Medicare coverage criteria and the option/accessory itself is medically necessary. The requested accessories 
have been denied because the enrollee does not require an arm height that is different from that available using 
an adjustable arm and the enrollee spends at least two (2) hours per day in the wheelchair. It is stated by the 
treating physician that this wheelchair is to be used to allow the enrollee to leave their home. The item at issue 
in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan 
covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve 
adjustable height, detachable armrest (CPT Code E0973), anti-tipping device (E0971), and heel loop/holder 
(E0951).