Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve medical nutrition therapy services.  You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee does not have a covered condition.  The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes.   We looked at the file and the rules. The records do not show that the enrollee suffers from renal disease or diabetes. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve medical nutrition therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the visual field assessment.  You asked the Plan to pre-approve the visual field assessment. You say that you would like reconsideration because this service was medically necessary. The Plan denied your request. The Plan says this service is considered 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 visual field assessment. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient evidence that visual field assessment with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; technical support and patient instructions, surveillance, analysis, and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional, is superior to standard monitoring and significantly impacts outcomes.  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 visual field assessment have not been met. Therefore, we decided that the Plan does not have to pre-approve the visual field assessment.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a non-emergency transportation taxi (A0100).  You asked the Plan to pre-approve a non-emergency transportation taxi. You say that there are no other specialists closer to the enrollee. You also say the enrollee does not have means of transportation and is not able to afford a cab service out of pocket. The Plan denied your request. The Plan says you are requesting an additional 6.8 miles for a total of 66.8 miles and your benefit only allows 60 miles.  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 up to 12 one-way trips and each one-way trip must not exceed 60 miles of driving distance.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, trips over 60 miles are not covered. Therefore, we decided that the Plan does not have to pre-approve a non-emergency transportation taxi (A0100).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency department services and pay for the self-administered drugs, provided on October 8, 2021, to October 9, 2021.  You asked the Plan to waive the copayment for the emergency department services and pay for the self-administered drugs. You say that the services should be covered. The Plan denied your request. The Plan says the cost share was applied correctly for the emergency room services and self-administered drugs are not covered.  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 $90 copay for emergency care.   You have been asked to pay a $90 copay for the emergency department services and pay for the self-administered drugs. The emergency department services fall within the emergency care 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. Medicare Part B generally does not pay for drugs that are usually self-administered by the patients who take them. Therefore, we decided that the Plan does not have to waive the copayment for the emergency department services and pay for the self-administered drugs, provided on October 8, 2021, to October 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the oral hygiene instructions (D1330), provided on October 14, 2021.  You asked the Plan to pre-approve the oral hygiene instructions. You say that the service should be covered. The Plan denied your request. The Plan says this is not a covered service.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the oral hygiene instructions (D1330), provided on October 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the insertion of subcutaneous cardiac rhythm monitor.  You asked the Plan to pre-approve the insertion of subcutaneous cardiac rhythm monitor. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the requested service.  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 subcutaneous cardiac rhythm monitor. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for an ILR.  In summary, there is insufficient documentation to support the medical necessity for insertion of an ILR in this member's clinical management.  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 subcutaneous cardiac rhythm monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of subcutaneous cardiac rhythm monitor.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for a home visit service provided on October 1, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the home visit service. You say that it was on the facility to get the authorization and it was medically necessary to treat the enrollee. The Plan denied your request. The Plan says the provider is not a network provider and there was no referral from an in-network provider with a prior authorization. The services provided were also not urgent or emergent.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 a home visit service provided on October 1, 2021, by an out-of-network (OON) provider.
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 inpatient rehab is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's ongoing skilled therapy and nursing needs can be provided in 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 in the Medicare rules section.  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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Aduhelm (J0172).  You asked the Plan to pre-approve Aduhelm. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage of Aduhelm have 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 Aduhelm. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 76-year-old man with a diagnosis of early onset Alzheimer's disease. In this case, the clinical documentation is inconsistent, and does not suggest that Aduhelm is medically reasonable and necessary for the enrollee in this case. There is no documentation of a Mini-Mental State Examination (MMSE) or other measure of cognition in this case. In addition, the magnetic resonance imaging (MRI) scan in this case suggests the presence of cerebrovascular disease, which is evidence of a mixed etiology for the enrollee's symptoms. Lastly, it has not been shown that Aduhelm is at least as beneficial as existing and appropriate and available medically appropriate alternatives for this 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 Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm (J0172).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.  You asked the Plan to pre-approve the requested scan. The Plan denied your request. The Plan says the enrollee does not meet the criteria.  The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.    We reviewed the file and the Medicare rules. We find that the enrollee does not have a tobacco smoking history of at least 30 pack years. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Janumet for the enrollee.  You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says 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 Janumet 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for onabotulinumtoxina injections (J0585) rendered on October 5, 2021.  You asked the Plan to waive the coinsurance for onabotulinumtoxina injections. You say that you were told by the Plan and the doctor's office that you were only responsible for a $50 copayment for your Botox injections for your chronic migraine, and now you are seeing there is more money that you may be responsible for. You also say that you are on disability with a limited income. The Plan denied your request. The Plan says you were charged the correct cost sharing amount  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for chemotherapy drugs, infusion drugs, and all other drugs covered under Medicare Part B. Your contract with the Plan also says that Medicare Part B drugs are subject to the 20% coinsurance plus any applicable copayment, depending on the location of service.   You have been asked to pay $243.20 in coinsurance, which is 20% of the allowed amount for onabotulinumtoxina injections ($1216 allowed amount x 20% coinsurance = $243.20). Onabotulinumtoxina injections fall within the Medicare Part B prescription drugs 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 onabotulinumtoxina injections (J0585) rendered on October 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Keytruda, Abraxane, and Carboplatin.  You asked the Plan to pre-approve Keytruda, Abraxane, and Carboplatin. You say that this is medically necessary. The Plan denied your request. The Plan says this treatment is not supported.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Keytruda, Abraxane, and Carboplatin. Our reviewer says that the requested use of Keytruda, Abraxane, and Carboplatin is not supported. Our physician reviewer found the Food and Drug Administration has not stated that the requested treatment is indicated for the enrollee's condition. The Medicare-approved cancer drug compendia do not contain a supportive citation for the use of the requested drugs in the enrollee's clinical situation.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda, Abraxane, and Carboplatin have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda, Abraxane, and Carboplatin.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for chiropractic services provided from August 12, 2021, to September 8, 2021, and billed under codes 99202 and 97110.  You asked the Plan to pay for codes chiropractic services coded as 99202 and 97110. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says while a portion of these services will be paid, those services not related to manual manipulation of the spine are not covered by Medicare or the Plan.   The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services denied are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services provided from August 12, 2021, to September 8, 2021, and billed under codes 99202 and 97110.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Orthovisc.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that Orthovisc is covered when specific 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have osteoarthritis in both knees and chronic knee pain. You received Euflexxa injections in December of 2020 with significant relief. You had another series of Euflexxa injections on January 21, 2022 and one planned on January 28, 2022 that was cancelled. You are now requesting Orthovisc. You do not meet the criteria for coverage of Orthovisc, as you have osteoarthritis on imaging and had a prior imaging series done with relief. There is no indication that knee surgery is being considered as a current treatment option. The last series of injections was done six months prior. Orthovisc is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection services (62320) provided on September 6, 2021.  You asked the Plan to pay for the injection services. You say that you would like this claim reprocessed an approved for payment. The Plan denied your request. The Plan says necessary documentation for payment was not received.  The Plan must follow Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.  We looked at the file and Medicare rules. In this case, no medical records were provided to corroborate the services as billed. Based on this information, we decided that Medicare rules for coverage of the injection services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services (62320) provided on September 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee is receiving medically necessary acute and/or critical care. The enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which an LTACH may offer a therapeutic advantage.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. 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 he 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.   The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.