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

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 13, 2021.

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 Medicare denies coverage for all cardiovascular risk assessment testing genomic screening panels for suspected or documented cardiovascular disease.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the member had a molecular genetic cardiac screening panel, the Hereditary Cardio Screen.

Medicare denies coverage for all cardiovascular risk assessment testing genomic screening panels for suspected or documented cardiovascular disease.Medicare denies coverage for all cardiovascular risk screening assessment genomic testing panels for suspected or documented cardiovascular disease. Medicare only covers a lipid panel consisting of a total cholesterol, HDL cholesterol, and triglyceride every 5 years, as cardiovascular screening testing. The services at issue in this case were 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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the limited oral evaluation and extractions provided by an oral surgeon.

You asked the Plan to pre-approve the limited oral evaluation and extractions. You say that you need eight extractions and need to be put to sleep. You say that the oral surgeon is needed to complete the procedure as the general dentist cannot do it. The Plan denied your request. The Plan says coverage is only provided for dental services performed by a participating general dentist.

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, services from an oral surgeon are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the limited oral evaluation and extractions provided by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies for the enrollee.
You asked the Plan to pre-approve incontinence supplies. You say that incontinence supplies are medically
necessary for the enrollee. The Plan denied your request. The Plan says incontinence supplies are not covered
by Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this
case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not
have to pre-approve incontinence supplies for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).
You asked the Plan to pre-approve a pneumatic compression device. You say that you are appealing the denial
as the enrollee has factor 5 blood clotting disorder. The Plan denied your request. The Plan says items that are
used for a preventative service or function is excluded for coverage under the Medicare DME benefit.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to
pre-approve a pneumatic compression device (E0676).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
You asked the Plan to pre-approve the additional non-emergency transportation. You say that you need additional trips for doctors' appointments because you can no longer drive and family members cannot take you. The Plan denied your request. The Plan says you have used all 10 trips and your benefit has been exhausted. The Plan also says that additional trips are not covered.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of up to 10 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute
setting.
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. The enrollee
is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the
LTACH that are not available at the acute care hospital where she is currently receiving care. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare
criteria for LTACH services.
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 the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power
options.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no need for multiple power options.
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 services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the plan will approve a group 3 power wheelchair with no power options but is denying the
version with multiple power options. Based on the medical records provided, there is no documentation that the
multiple power options meet Medicare criteria for necessity in this case. The records do not document a need
for tilt and recline, as defined by the Medicare criteria. The records do not document that you have a current
pressure ulcer or history of a pressure ulcer. There is no documentation that you require self-catheterization or
has spasticity on exam. You appear to meet criteria for a group 3 power wheelchair with no power options.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a group 3 power wheelchair with multiple power options.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received
from July 8, 2021, to July 26, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were admitted
to one hospital and then discharged. you were admitted to a different hospital a week later. You stated that
you were told there would just be one copayment for both admissions because you were readmitted within 60
days. 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 $395
copayment per day for days 1-5, and a $0 copayment for additional days for inpatient hospital care.
Records show that you were in the hospital for 18 days. You were charged a $395 copayment per day for the
first 5 days, for a total of $1975. According to your contract, the inpatient hospital copayment applies each
time you are admitted, regardless of the reason for the admission. 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 inpatient hospital services you received from July 8, 2021, to July 26, 2021
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa 20 mg/2ml syringe for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says the plan's preferred viscosupplements are Orthovisc and Monovisc, which don't require
prior authorization.
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 drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found the plan requires a trial
of Orthovisc and Monovisc before they will approve the requested drug. In this case, the enrollee has not tried
and failed the required drugs. There is no documentation provided indicating that the plan's required drugs
would likely be less effective and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Euflexxa 20 mg/2ml syringe for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom shoe inserts.

You asked the Plan to pre-approve foot orthotics. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve custom shoe inserts.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from December 11, 2021,
forward.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee no longer qualifies for SNF
coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have
documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program
or to prevent deterioration of the enrollee's condition. The enrollee's care needs are custodial and, as a practical
matter, can be provided at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve continuation of SNF care from December 11, 2021, forward.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
You asked the Plan to pre-approve the additional non-emergency transportation. You say that you cannot walk
and need to talk to your podiatrist. The Plan denied your request. The Plan says as of November 19, 2021 you
have used 43 one-way trips this year and have 9 one-way trips available. The Plan also says that although you
disenrolled and then re-enrolled in this plan, the previous balance of used trips will carry forward to the rest of
the calendar year and a reset will not be triggered in the balance of trips available.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage.
For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of fifty-two (52) one-
way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you will or have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acupuncture services to be provided by an out-of-
network (OON) provider.
You asked the Plan to pre-approve the acupuncture services. You say that you are appealing this denial for an
out-of-network acupuncturist. The Plan denied your request. The Plan says the provider is 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 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. The records provided for review do not show that the services at
issue are urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the acupuncture
services to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the diagnostic mammogram and breast ultrasound you had on July 21, 2021.
You asked the Plan to waive the copayments for the diagnostic mammogram and breast ultrasound. You say that you were told this was covered in full. The Plan denied your request. The Plan says you were charged these copayments 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 $50 copayment for diagnostic radiology services. You have been asked to pay a $50 copayment for the diagnostic mammogram and breast ultrasound. The diagnostic mammogram and breast ultrasound fall within the diagnostic radiology 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 copayments for the diagnostic mammogram and breast ultrasound you had on July 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intravitreal injections (67028) with Lucentis (J2778) to
be provided by an out-of-network tertiary-care provider.
You asked the Plan to pre-approve intravitreal injections. You say that the requested tertiary care is a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not
been met.
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 provider at issue in this case is not a network provider with the Plan. 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 intravitreal injections. Our reviewer says that the requested out-of-network
care is not medically necessary in this case. Our physician reviewer found that the enrollee was seen by the out-
of-network tertiary provider for a second opinion.
The record indicates that the Plan has network providers capable of providing the requested services. The
elements of the coverage criteria are not satisfied.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of intravitreal injections have not been met. 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 intravitreal injections. Therefore, we decided that the Plan does not have to pre-approve
intravitreal injections (67028) with Lucentis (J2778) to be provided by an out-of-network tertiary-care
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in tub.
You asked the Plan to pre-approve a walk-in tub. You say that a walk-in tub is medically necessary to improve
your leg. The Plan denied your request. The Plan says a walk-in tub is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose. The rules say that shower or bath equipment specifically is not covered. A walk-in tub 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 a walk-in tub.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on April 13, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says it cannot determined how the member came to the servicing provider, or whether the services are medically necessary.

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. The documentation submitted does not contain medical records from the non-contract provider. Without records, it cannot be confirmed that Medicare coverage criteria have been met. 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 the services provided on April 13, 2021.