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

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that the enrollee developed significant midfoot collapse with a traumatic arthropathy involving both feet. The Plan denied your request. The Plan says this item is 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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a shower chair.  You asked the Plan to pre-approve a shower chair. You say that you cannot stand for long periods of time. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.   While a shower chair 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 shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve incontinence supplies.  You asked the Plan to pre-approve incontinence supplies. You say that this product will help the enrollee when entering the catheter. The Plan denied your request. The Plan says this item is not a covered benefit.  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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a shower chair.  You asked the Plan to pre-approve a shower chair. You say that you are a post-polio patient and cannot walk or stand in the shower because of your weak condition. You say that you fell in the bathroom, broke your hip, and have never recovered. You say that you have to use a walker to get in and out of the shower in order to bathe. You say that you are currently using a broke and rusted shower chair, which is dangerous. The Plan denied your request. The Plan says a bath/shower chair is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.   While a shower chair 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 shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that this is needed for pain from heel spurs. The Plan denied your request. The Plan says this item is 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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eligard.  You asked the Plan to pre-approve Eligard. You say that the medication is 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 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 Eligard. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Eligard have not been met. Therefore, we decided that the Plan does not have to pre-approve Eligard.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the over-the-counter items purchased from September 5, 2021, through September 26, 2021.  You asked the Plan to pay for the over-the-counter items. You say that you submitted receipts requesting reimbursement for the over-the-counter items. The Plan denied your request. The Plan says your $550 benefit was met on March 2, 2021.  Though the Plan offers an over-the-counter benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Specifically, the Plan paid $550 on March 2, 2021 toward the items purchased on February 8, 2021 and February 22, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the over-the-counter items purchased from September 5, 2021, through September 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and supplies for the enrollee.  You asked the Plan to pre-approve a CGM and supplies. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the member is not using insulin.  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. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and supplies for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Medtronic continuous glucose monitor sensors (A9276).  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare only covers therapeutic continuous glucose monitoring systems.  The Plan must follow Medicare rules. The rules say that Healthcare Common Procedure Coding System (HCPCS) A9276 is not a covered code.  The requested monitor is coded in such a way that makes it statutorily not covered by Medicare. 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 Medtronic continuous glucose monitor sensors (A9276).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the consultation to be provided by an out-of-network provider.  You asked the Plan to pre-approve the out-of-network consultation. You say that you are aware that this provider is not in-network with your Health Plan. The Plan denied your request. The Plan says there are in-network providers that can provide the services you are requesting.  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 consultation to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for foot orthotics.  You asked the Plan to pay for foot orthotics. You say that you were told this equipment was covered by your Plan. You say that you are pre-diabetic and orthotics are medically necessary. The Plan denied your request. The Plan says this item is 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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor for the enrollee.  You asked the Plan to pre-approve the sensor. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria is not met.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 assesses 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. The enrollee only takes insulin at bedtime. Based on this information, we decided that Medicare rules for coverage of the sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable home ventilator.  You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says a ventilator setting that could be delivered by BiPAP is not covered.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 requested services. Our physician reviewer found that you have diagnoses of COPD and chronic respiratory failure. The mode of ventilation to be used with the requested portable home ventilator is IVAPS with AE. Per coverage criteria, products when used to provide CPAP or bi-level PAP (with or without back-up rate) therapy, regardless of the underlying medical condition, shall not be covered.  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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable home ventilator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve outpatient therapies (97116, 97110, 97112, 97530) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve out-of-network therapy. You say that the enrollee needs therapy from this provider because they are home-bound and are afraid of falling. The Plan denied your request. The Plan says out-of-network services are only covered in certain limited circumstances. The requested therapy is not urgent or emergent, and the requested services can be performed by in-network providers. The out-of-network therapy is denied in this case.  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, including in-network therapy provided in the enrollee's home. 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 outpatient therapies (97116, 97110, 97112, 97530) to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the office services and treatment to be provided by an out-of-network provider.  You asked the Plan to pre-approve the out-of-network services. You say that you are in the process of scheduling your next appointment and procedure and have no desire or intention of seeing the doctor again due to your dissatisfaction with the care received and not being able to schedule timely appointment with providers within the network. The Plan denied your request. The Plan says they reached out to the doctor's office and were advised that they had arranged an appointment on September 23, 2021. The Plan states the office said you called to cancel the appointment. The Plan states your records show that you visited the out-of-network urologist at UCSD 2 weeks later October 8, 2021. The Plan states they are required to provide exceptions for care that cannot be provided in-network or for urgent or emergent medical care when you are out of the network area. The Plan states after reviewing your appeal and the available medical records, they determined that a network provider can care for your medical problem. The Plan states they understand that you do not wish to see  the doctor, but there are other urologists in the office and your group may also be able to arrange for an in-network urologist in a different group if you contact them.  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 office services and treatment to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve deep brain stimulation to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the OON deep brain stimulation. You say that you would like the enrollee to see the requested OON provider because they offer deep brain stimulation therapy for Parkinson's. You say that the enrollee has the right to choose what specialist they would like to see.  The Plan denied your request. The Plan says there are in network providers who they have confirmed are able to perform deep brain stimulation therapy treatment.  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 deep brain stimulation to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.  You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says only two insulin injections are received per day.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 assesses 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. The records show that there are only two insulin injections per day.. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis tablets.  You asked the Plan to pre-approve Eliquis tablets. You say that this is the best medication for the enrollee. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.  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 Eliquis tablets.  Benefits for Eliquis tablets 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 pre-approve water pool therapy.  You asked the Plan to pre-approve water pool therapy. You say that the documentation provided supports that the requested service is medically necessary. The Plan denied your request. The Plan says the requested treatment is considered experimental and investigative. The Plan says that the requested treatment is not medically necessary.  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 water pool therapy. Our reviewer says that water pool therapy is not considered medically reasonable and necessary in this case. Our physician reviewer found the requested Float therapy exceeds the enrollee's medical needs and is not proven to be effective for the enrollee's chronic pain. Additionally, the documentation does not reveal objective functional deficits on a recent physical exam that require professional skilled therapy. The enrollee has full extremity range of motion, normal station and gait, and a normal get up and go test. There is no evidence that the enrollee is unable to participate in land-based therapy.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of water pool therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve water pool therapy.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pre-approve cataract extraction surgery.  You asked the Plan to pre-approve cataract surgery. You say that the enrollee has a nuclear cataract and cannot see while driving. The Plan denied your request. The Plan says that the enrollee does not meet the coverage requirements for cataract surgery.  The Plan follows Medicare rules. Medicare rules state that cataract extraction surgery may be covered when certain criteria are met.     We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve cataract surgery. Our reviewer says that the enrollee meets the Medicare criteria for the requested cataract surgery. Our physician reviewer found the enrollee has complaints of poor vision and specific activities being limited such as driving. The evidence of visual disability is supported with visual acuity of 20/30 and cataract on examination. The Plan's argument that visual acuity must be worse than 20/40 is not valid according to Medicare rules. Medicare rules state that "for patients with a best corrected visual acuity of 20/40 or better, cataract extraction will be considered if all other criteria have been met and there is substantial documentation of the medical necessity for that patient." The enrollee meets the requirements set forth in Medicare rules and standards of care for medically necessary cataract surgery.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of cataract surgery have been met. Therefore, we decided that the Plan has to pre-approve cataract extraction surgery.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.