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

We decided that the Plan does not have to pre-approve the Superion interspinous spacer for the enrollee.

You asked the Plan to pre-approve the spacer. You say that this is medically necessary. The Plan denied your
request. The Plan says a review of the current medical literature indicates that this service is considered
experimental and investigational.

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 spacer. Our reviewer says that the
requested spacer is not considered medically reasonable and necessary in this case. Our physician reviewer
found the device is experimental. More research is needed t show safety and efficacy.

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 spacer have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Superion interspinous spacer for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from February 18, 2019, to
May 31, 2019.

You asked the Plan to pay for this service. You say that these services should be paid by the Plan. The Plan
denied your request. The Plan says this claim was filed after the Medicare time limit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service. The record shows that a claim for this
service was not filed until September 1, 2020. This means that more than one calendar year from the date of
service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for
chiropractic services provided from February 18, 2019, to May 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a shingles vaccine provided on June 30, 2020.

You asked the Plan to pay for this service. You say that this vaccine should be covered by the Plan. The Plan
denied your request. The Plan says this vaccine is not covered under Medicare Part B.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide this service. The
Plan follows the same rules. The records do not show that you have been injured or directly exposed to any
illness related to this service. Therefore, we decided that the Plan does not have to pay for a shingles vaccine
provided on June 30, 2020.

Benefits for this service 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport you had on April
25, 2020.

You asked the Plan to waive the copayment for the ambulance transport. You say that due to the pandemic, you
had to use an ambulance instead of having your husband drive you to the emergency room. The Plan denied
your request. The Plan says you were charged this copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300
copayment per trip for ambulance services.

You have been asked to pay a $300 copayment per trip for the ambulance transport. This copayment applies
regardless of the reason for the ambulance transport. 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 transport you had on April 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health care.

You asked the Plan to pre-approve the inpatient mental health care. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 
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 inpatient mental health care. Our reviewer says that continued inpatient services are not medically necessary. Our physician reviewer found the enrollee was not a danger to himself or others and was cooperative and compliant. It does not appear that active treatment was taking place. It does not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. 

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 inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia syringes to be provided by a pharmacy.

You asked the Plan to pre-approve Prolia. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B when dispensed to the enrollee by a pharmacy.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia syringes to be provided by a pharmacy.
Benefits for Prolia 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: Unfavorable

We decided that the Plan does not have to pre-approve Travatan Z eye drops for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under 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 Travatan Z eye drops for the enrollee.

Benefits for this drug 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July
25, 2020.

You asked the Plan to pay for the comprehensive oral evaluation. You say that your previous dental facility
would not see anyone due to the pandemic. You also say that you found a new dentist on your own because
you could not get ahold of your Plan representative. The Plan denied your request. The Plan says this service
exceeds the maximum count allowed per period.

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, comprehensive oral evaluation
(D0150) is limited to one procedure every three plan years. The record shows that you received a
comprehensive oral evaluation (D0150) on October 24, 2018, and your comprehensive oral evaluation (D0150)
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive
oral evaluation (D0150) provided on July 25, 2020.

Your complaint about the possible lack of communication from the Plan 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the neuropsychological testing provided
on February 5, 2020.

You asked the Plan to waive the coinsurance for the neuropsychological testing. You say that you paid the bill
but should be reimbursed. The Plan denied your request. The Plan says the coinsurance applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 40%
coinsurance for Medicare-covered non-radiological diagnostic services from an out-of-network provider.

You have been asked to pay a total of $400.48, which is 40% of the allowed amount for the neuropsychological
testing. The allowed amount is $1,001.19 (40% x $1,001.19 = $400.48). The neuropsychological testing 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 coinsurance for the neuropsychological testing provided on February 5, 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.

You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower 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 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. Our physician reviewer found the patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. 

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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Factor V Leiden testing.

You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your
request. The Plan says there is not enough medical evidence at this time to show that this testing would be
helpful.

The Plan must follow Medicare rules. Medicare rules say that Factor V Leiden testing is only covered for
pregnant patients.

The enrollee does not qualify for this testing. Based on this information, we decided that Medicare rules for
coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pre-approve
Factor V Leiden testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on December 17, 2019.

You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says the Plan
requires utilization of network providers when possible and available, and requires authorization for certain
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has
been documented.

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 did not pre-approve the
psychotherapy services. 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 psychotherapy services provided on December 17,
2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vascepa 1 gm capsule.

You asked the Plan to pre-approve Vascepa. You say that the drug is medically necessary to treat enrollee's condition. The Plan denied your request. The Plan says this is not a medical necessity denial. Medicare says Part B programs can only provide limited benefits for prescription drugs.

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 Vascepa 1 gm capsule.

Benefits for Vascepa 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan of extremity veins provided on February 1,
2020.

You asked the Plan to pay for the duplex scan of extremity veins. The Plan denied your request. The Plan says
the Plan requires utilization of network providers when possible and available, and requires authorization for
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency
situation, has been documented.

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 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 a duplex scan of extremity veins provided on February 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services provided from May 2, 2020, to August
8, 2020.

You asked the Plan to pay for acupuncture services. You say that these services were medically necessary for
treatment of migraines. The Plan denied your request. The Plan says these services are not covered under the
Plan contract.

Medicare only covers 12 acupuncture visits for chronic low back pain. The Plan does not cover acupuncture
under any circumstance. Your treatment was for migraines. Therefore, we decided that the Plan does not have
to pay for acupuncture services provided from May 2, 2020, to August 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walker provided on February 17, 2020.

You asked the Plan to pay for equipment from this provider. You say that this walker should be covered by the
Plan. The Plan denied your request. The Plan says the provider is not a Medicare eligible provider.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program. This
provider is not a Medicare eligible durable medical equipment provider. Therefore, we decided that the Plan
does not have to pay for a walker provided on February 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc injections for the enrollee.
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says there is no radiological evidence of osteoarthritis.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injections. Our reviewer says that the requested injections are not medically reasonable or necessary. Our physician reviewer found as there is no radiographic documentation of osteoarthritis, medical necessity has not been established. The service is not medically reasonable or 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc injections for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the referral. You say that you want a provider within a 50 mile radius. The Plan denied your request. The Plan says there is a network provider available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tagrisso tablets.
You asked the Plan to pre-approve Tagrisso tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Tagrisso tablets are not covered under the enrollee'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 Tagrisso tablets.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80053, 85027, 83036, 80164, P9604, P9603) provided September 20, 2019 to December 26, 2019.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
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 codes 80053, 85027, 83036, 80164, P9604, & P9603 are not supported in the medical record. Specifically, the documentation did not include a valid physician order and the place of service noted on the claim did not match the place of service specified in the records. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (80053, 85027, 83036, 80164, P9604, P9603) provided September 20, 2019 to December 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing services provided to the enrollee on June 22, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says if a single procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the procedure
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing services provided to the enrollee on June 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OTEZLA TAB 30MG.
You asked the Plan to pre-approve OTEZLA TAB 30MG. You say that the item is medically necessary. The Plan denied your request. The Plan says The Medicare Advantage (MA) plan does not cover outpatient prescription drugs.
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 OTEZLA TAB 30MG.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services on December 5, 2019.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on December 5, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services on December 5, 2019.