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

We decided that the Plan does not have to pre-approve a OneTouch Verio Test Strip for the enrollee.
You asked the Plan to pre-approve the test strip. You say that this is medically necessary. The Plan denied your
request. The Plan says it has other preferred meters and test strips.
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 test strip. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found there is no specific clinical rationale for the requested test strips. There is no specific clinical rationale
for the enrollee's specific glucometer. The Plan has other preferred meters and test strips. The review has
determined that there is no specific medical necessity for the requested brand. The requested OneTouch Verio
Test Strips are not medically necessary and reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the test strip have not been met. Therefore, we decided that the Plan does not
have to pre-approve a OneTouch Verio Test Strip for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tdap vaccine you received on December 9, 2019.
You asked the Plan to pay for the vaccine. You say that you were advised that you needed this vaccine, but were not told that it would not be covered. The Plan denied your request. The Plan says this is not a covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the Tdap vaccine you received on December 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Doxepin cream.
You asked the Plan to pre-approve the Doxepin cream. You say that the medical records provided support the need for the requested drug. The Plan denied your request. The Plan says the enrollee has a medical only policy with the plan. The Plan says that the enrollee's drug coverage is therefore limited to Medicare Part B covered drugs. The Plan says that the enrollee should contact their prescription drug plan to determine coverage of the requested drug.
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 Doxepin cream.
Benefits for the Doxepin cream 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device (22869).
You asked the Plan to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.
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 insertion of interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device remains experimental. More research is needed before it can be considered 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 insertion of interlaminar/interspinous process stabilization/distraction device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device (22869).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Forteo 600 mcg/2.4 ml pen injection.
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the member has a medical (MA) only policy with the plan, not a Prescription Drug Plan (PDP). Therefore, drug coverage is limited to Medicare Part B covered 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 drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Forteo 600 mcg/2.4 ml pen injection.
Benefits for this medication 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy (PT) provided on May 15, 2019 through July 22, 2019. 
 
You asked the Plan to waive the copayment for PT. You say that you were told by the provider that you would have no copay. You don't feel responsible for the $40 copay. The Plan denied your request. The Plan says there is a $40 copayment for PT. 
 
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 $40 copayment for outpatient rehabilitation services.  
 
You have been asked to pay a $40 copayment for PT. This service falls within the outpatient rehabilitation services benefit category. Payments for the months of May, June and July are $160 + $280 + $240 = $680. 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 physical therapy (PT) provided on May 15, 2019 through July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on August 26, 2019 by out of
network provider.
You asked the Plan to pay for outpatient lab work. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The
Plan says that the referring provider is also out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for outpatient lab work provided on August 26, 2019
by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto.
You asked the Plan to pre-approve the Entresto. You say that the drug being requested is medically necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy with the Plan and not a Prescription Drug Plan. The plan says that the requested drug is not covered under Medicare Part B and the enrollee should contact their Prescription Drug Plan to determine coverage.
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 Entresto.
Benefits for the Entresto 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 pre-approve the medical services to be provided by out of network (OON) orthopedic provider.
You asked the Plan to pre-approve the OON orthopedics consultation. You say that you need to see this provider immediately since you are in a lot of pain. The Plan denied your request. The Plan says this provider is not in-network with your plan. There is a network provider  within 6 minutes of your home who can provide this care.
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 pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. 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 out of network (OON) orthopedic provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network (OON) allergist.
You asked the Plan to pre-approve the OON allergist services. You say that you were treated by an in-network allergist in the past and were given a limited set of testing and were told that you had no allergies after which you had a severe anaphylactic reaction. When you began treatment, she was able to identify your allergies and provide treatments which have been useful and beneficial. You feel that these quarterly visits should be covered by the plan. The Plan denied your request. The Plan says there are two in-network allergists in your area. There is no evidence that you have seen the specialists offered by the plan. You are required to use network providers unless there are none available. Since there is no network deficiency, the requested OON referral is not approved.
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 pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. Although you had a bad experience with a network provider in the past, there is no evidence that only the OON provider is able to treat your condition. 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 out of network (OON) allergist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for items and services applied to the 2019
maximum out-of-pocket amount from January 1, 2019 to October 21, 2019.
You asked the Plan to waive the cost-sharing for maximum out-of-pocket amount. You say that you have paid
more than the maximum out-of-pocket amount for 2019. The Plan denied your request. The Plan says the cost-sharing
amounts you have been charged are correct.
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 the most you must pay
out-of-pocket for covered items and services in 2019 is $3,400. This is called the maximum out-of-pocket
amount. A summary of your 2019 maximum out-of-pocket amount is shown on the following page:
A total of $3,178.38 has been applied to your 2019 maximum out-of-pocket amount, therefore you have not
met or exceeded the $3,400 total maximum out-of-pocket amount for 2019. Therefore, we decided that the Plan
does not have to waive the cost-sharing for items and services applied to the 2019 maximum out-of-pocket
amount from January 1, 2019 to October 21, 2019.
Your complaint regarding receiving inaccurate information about the total amount applied to your 2019
maximum out-of-pocket amount is considered to be a grievance. MAXIMUS Federal Services does not have
the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift.
You asked the Plan to pre-approve a stair lift. You say that the requested device is not for convenience and is medical in nature. You say that you have been unable to shower in months because all bathrooms and beds are upstairs. You say that you are unable to heal properly because of poor sleeping availability and the inability to have your wound be properly sanitized. The Plan denied your request. The Plan says the requested item is a non-covered benefit under Medicare and the plan.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair lift.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on December 7, 2019.
You asked the Plan to pay for the psychotherapy services. You say that you have been under the care of this physician for 17 years and you do not want to change to another doctor. The Plan denied your request. The Plan says on-emergent, non-urgent services with out-of-network providers require 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 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 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan (Hyaluronate).
You asked the Plan to pre-approve Hyalgan. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the information submitted does not meet the the Plan's medical necessity guidelines for coverage. The Plan says that the enrollee has not had previous treatment with, contraindication, or intolerance to Orthovisc and Monovisc.
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 Hyalgan. Our reviewer says that the criteria for the requested drug have not been met. Our physician reviewer found the records do not show that the enrollee has tried and failed Monovisc and Orthovisc. The documentation does not support that Monovisc and Orthovisc 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan (Hyaluronate).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider. 
 
You asked the Plan to pre-approve urology visit. You say that you have to see this doctor every 6 months to check if cancer has re-occurred. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with your Plan medical group and you can be treated by an in-network urologist. 
 
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 pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. 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 out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Airhawk Lightweight Folding Electric Wheelchair (coded as 1399), for the enrollee.
You asked the Plan to pre-approve the electric wheelchair. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says a more appropriate code would be K0813 - Power wheelchair, group 1 standard, portable, sling/solid seat and back. The Plan states you do qualify for the power wheelchair coded as K0813 if obtained from a Medicare and the Plan contracted supplier, such as: National Seating and Mobility St. Louis 502 Earth City Plaza, Suite 200 Earth city, MO 63045-1315 (833) 386-9235 (314) 480-6157. The Plan states they spoke with Chrissy who states they are able to provide any standard Medicare covered power wheelchair including the K0813 to this area.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the electric wheelchair have not been met. The medical record from your nurse practitioner indicates you have difficulty walking and need the device to help with mobility and achieving more independence with your activities of daily living, and you are unable to self-propel. Your provider stated that you saw the Airhawk wheelchair on TV and you feel it would enhance your independence. Your request does not meet the conditions for approval because the Airhawk wheelchair has additional features that exceed your need because they are designed for use outside the home. Additionally, this supplier of this device has stated that they do not participate with Medicare. Therefore, we decided that the Plan does not have to pre-approve the Airhawk Lightweight Folding Electric Wheelchair (coded as 1399), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement power wheelchair.
You asked the Plan to pre-approve a replacement power wheelchair. You say that the enrollee's current power wheelchair is over five years old and you want the enrollee to have a new one. The Plan denied your request. The Plan says there is no indication of the current wheelchair not meeting the enrollee's needs.
The Plan follows Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF to be a home.
Records show that a replacement power wheelchair is being requested for use in a SNF. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99212), and a pregnancy test (81025) provided on April 15, 2019 by out of network provider.
You asked the Plan to pay for an office visit and a pregnancy test. You say that you are seeking a review and requesting payment. You say the services were rendered based on the patient's medical condition. The Plan denied your request. The Plan says the non-urgent service is not authorized because the Dr. is a non-network provider who does not work with the Plan and the member self-directed for services. The member's primary care physician (PCP) did not refer for services. The health 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit (99212), and a pregnancy test (81025) provided on April 15, 2019 by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee from September 4, 2019 to September 11, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee from September 4, 2019 to September 11, 2019.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.