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

We decided that the Plan does not have to waive the copayment for a sacroiliac joint injection provided on June 30, 2021.

You asked the Plan to waive the copayment for a sacroiliac joint injection. You say that you were told that you would only owe a $110 copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 a $260 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. 

You received a sacroiliac joint injection at an ambulatory surgical center on June 30, 2021.A sacroiliac joint injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $260 copayment.

You have been asked to pay a $260 copayment for a sacroiliac joint injection. A sacroiliac joint injection falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 copayment for a sacroiliac joint injection provided on June 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve compression stockings. You say that the requested items are a medical necessity for you. The Plan denied your request. The Plan says the requested items are not a covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a follow-up visit, eye testing, and an eye injection to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested services.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a follow-up visit, eye testing, and an eye injection to be rendered by the 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.

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 you do not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from continued physical therapy, and occupational therapy, your rehab needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility. 

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
You asked the Plan to pre-approve the compression stockings. You say that you are in a lot of pain and your doctor said the stockings would reduce your pain. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6545 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network urologist.

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 available from network providers.

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 a referral to an out-of-network urologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor and related supplies.

You asked the Plan to pre-approve a continuous glucose monitor and related supplies. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for continuous glucose monitors have not been met.

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 continuous glucose monitor and related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor and related supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 19.

You asked the Plan to pre-approve the dental service. You say that the service is necessary. The Plan denied your request. The Plan says crown is not listed as 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 crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 19.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve shoe inserts (L3010).
You asked the Plan to pre-approve shoe inserts. You say that you need these for your chronic plantar fasciitis. The Plan denied your request. The Plan says these are not covered for your condition.
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 shoe inserts (L3010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies for the enrollee.

You asked the Plan to pre-approve a CGM and supplies. You say that these services. The Plan denied your request. The Plan says that this request does not criteria for coverage.

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 you do not perform blood glucose testing at least four times per day or 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 continuous glucose monitor (CGM) and supplies for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the catheter placement in coronary artery provided on August 9, 2021.

You asked the Plan to waive the coinsurance for the catheter placement in coronary artery. You say that you only paid $90 in the past and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct 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 outpatient surgery, including services provided at hospital outpatient facilities.

You received the catheter placement in a coronary artery at an outpatient hospital facility on August 9, 2021. The catheter placement in a coronary artery is considered an outpatient surgical procedure. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $2,754.92 and 20% of that is $550.98. 

You have been asked to pay the total coinsurance amount of $550.98 for the catheter placement in coronary artery. The catheter placement in coronary artery falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the catheter placement in coronary artery provided on August 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement Group 3 power wheelchair (K0861).
You asked the Plan to pre-approve a replacement power wheelchair. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that, in the absence of program instructions, the reasonable useful lifetime of equipment in no case can be less than 5 years. Computation of the useful lifetime is based on when the equipment is delivered to the enrollee, not the age of the equipment. We looked at the file and Medicare rules. In this case, you are requesting a replacement for a power wheelchair received by the enrollee in 2018.
Therefore, the requested replacement is for an item that has not outlasted its reasonable useful lifetime. Based on this information, we decided that Medicare rules for coverage of a replacement power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement Group 3 power wheelchair (K0861).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 23, 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 if a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.

You asked the Plan to pre-approve the compression stockings. You say that this should be paid for. The Plan denied your request. The Plan says the requested supplies are statutorily not covered by Medicare.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a mandibular partial denture (D5214).  

You asked the Plan to pre-approve the complete maxillary denture and mandibular partial denture. The Plan denied your request. The Plan says these services are allowed one time every 60 months. The Plan also says that you received these services less than 60 months ago.  

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, complete/partial dentures are limited to once per arch per 60 months. The record shows that you received a complete maxillary denture (D5110) on September 16, 2019, and you received a mandibular partial denture (D5214) on January 13, 2020 and your complete maxillary denture (D5110) and mandibular partial denture (D5214) benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a mandibular partial denture (D5214).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on June 22, 2021.

You asked the Plan to waive the copayment for ambulance services. You say that you did not request the transport and were told that you would not be charged. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 a $250 copayment for ambulance services. 

You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the ambulance 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 copayment for ambulance services provided on June 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on September 14, 2020.
You asked the Plan to pay for lab tests. You say that you are dependent on receiving patient information from the ordering provider. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in a skilled nursing facility setting, therefore the POS code 11 - indicating an office setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on September 14, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Fold and Go MagSHOCK wheelchair.  

You asked the Plan to pre-approve these services. You say that this wheelchair would allow you to take it with you to personal or outside functions. The Plan denied your request. The Plan says your power wheelchair meets your mobility needs.  

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.  

The file shows that you have a power wheelchair. The power wheelchair serves the same purpose as the requested Fold and Go MagSHOCK wheelchair. Furthermore, the file shows that you are requesting this item for use outside of the home and Medicare does not cover this item for that purpose. Therefore, we decided that the Plan does not have to pre-approve a Fold and Go MagSHOCK wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for transcutaneous electrical modulation pain reprocessing and acupuncture provided to the enrollee on July 6, 2021.

You asked the Plan to pay for the services. You say that this has been the only treatment that has helped with polyneuropathy. The Plan denied your request. The Plan says this service is considered investigational and therefore not medically necessary.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. 

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, acupuncture is only covered for chronic low back pain. Therefore, we decided that the Plan does not have to pay for transcutaneous electrical modulation pain reprocessing and acupuncture provided to the enrollee on July 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Truxima.

You asked the Plan to pre-approve Truxima. You say that Truxima is the standard of care. The Plan denied your request. The Plan says the combination of Truxima and Imbruvica are not recommended and have no proven benefit.

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 Truxima. Our physician reviewer found that the enrollee has a medical history of prostate cancer and chronic lymphocytic leukemia/small lymphocytic lymphoma. Coverage for treatment with Truxima, to be used in combination with ibrutinib has been requested. There is no documentation that the requested use of Truxima is FDA-approved for the enrollee's diagnosis given his age and comorbidities. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is not listed as not indicated, not supported, or not recommended in any of the compendia. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary 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 Truxima have not been met. Therefore, we decided that the Plan does not have to pre-approve Truxima.