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

We decided that the Plan does not have to pre-approve Daptomycin (J0878) 650 mg intravenous, daily for 42
visits.
You asked the Plan to pre-approve Daptomycin. You say that the requested treatment is medically necessary.
The Plan denied your request. The Plan says the requested drug is not medically necessary.
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 Daptomycin. Our reviewer says that the
requested drug, Daptomycin, is not medically necessary. Our physician reviewer found the requested use of
daptomycin is approved by the Food and Drug Administration (FDA) for the enrollee's diagnosis. The
reviewer found that there was no bone biopsy/culture obtained to confirm the diagnosis of osteomyelitis. The
reviewer also found that the documentation does not support that the requested drug, Daptomycin, 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 Daptomycin have not been met. Specifically, the file does not show that there
was a bone biopsy or culture obtained. Therefore, we decided that the Plan does not have to pre-approve
Daptomycin (J0878) 650 mg intravenous, daily for 42 visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve membrane graft wound care.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you have not failed conservative wound therapy.

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 requested services. Our physician reviewer found that you have a left great toe, full thickness ulcer and diabetes. A request for membrane wound graft care was made. The provided documentation did not clearly show that you have fully exhausted and failed conservative wound care treatments for at least 30 days prior to considering grafting treatment. Therefore, without sufficient support made, this request for membrane wound graft care will be considered not medically necessary at this time.

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 membrane graft wound care.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on August 31, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for vision services provided on August 13, 2021.  You asked the Plan to pay for vision services. The Plan denied your request. The Plan says the Plan will not pay the claim from an out of network provider. The benefit plan doesn't cover this out of network vision care.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The file shows that the services were not provided by the Plan's network vision care provider. Based on this information, we decided that the Plan's rules for coverage of vision services have not been met. Therefore, we decided that the Plan does not have to pay for vision services provided on August 13, 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 the enrollee cannot be adequately cared for at a skilled nursing facility. The Plan denied your request. The Plan says there is no advantage in moving the enrollee from the current acute care hospital.
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 physician reviewer found that the enrollee was admitted to the acute care hospital for acute hypoxic respiratory failure. His hospital course was complicated by coronavirus pneumonia, dehydration, bacteremia, and septic shock. He remains on full ventilator support. The enrollee is receiving appropriate care at the present acute care hospital. He 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 he 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.
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.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the SelectMDx testing provided on June 28, 2021.  You asked the Plan to pay for the SelectMDx testing. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says this testing can only be covered after an initial prostate biopsy, and there is no evidence that such a biopsy occurred.  The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests such as SelectMDx are subject to the MolDX application, assessment, and approval process. Once this is complee, the test is assigned a reimbursement rate and unique test identifier from the DEX Diagnostic Exchange.    We looked at the file and Medicare rules. Per review of the DEX Diagnostic Exchange, the SelectMDx test was reviewed through the MolDX process and was found to not meet Medicare coverage criteria. Therefore, we decided that the Plan does not have to pay for the SelectMDx testing provided on June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) provided on
October 22, 2021.
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that you did not approve of the
extra x-ray charge and do not feel that the charge is just or correct. The Plan denied your request. The Plan says
benefits for this service have been satisfied and the frequency limitation has been exceeded.
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, intraoral x-rays are limited to one
procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220)
on October 22, 2021, which was covered by the Plan, and your intraoral x-rays benefit has been exhausted.
Therefore, we decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230)
provided on October 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), and prophylaxis (D1110) provided
on October 14, 2021 by an out of network provider.
You asked the Plan to pay for the dental services. You say that the provider refused to give you a standard
cleaning or fill your tooth. You say that you did not want to drive 2 hours for another in network dentist. You
also say that the plan recording advised you could go to any dentist. The Plan denied your request. The Plan
says dental services you receive out of network are not covered.
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 pay for the oral
exam (D0120), and prophylaxis (D1110) provided on October 14, 2021 by an out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the outpatient facility charge for a nasal endoscopy provided on October 15, 2021.
You asked the Plan to reduce the copayment for the facility charge. You say that you were charged incorrectly. You also say that you should be responsible for a $20 copayment. The Plan denied your request. The Plan says you have been 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 a $200 copayment for outpatient hospital facility visits. You have been asked to pay the allowed amount of $158.37, which is less than the $200 copayment for the facility charge. The facility charge 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 reduce the copayment for the outpatient facility charge for a nasal endoscopy provided on October 15, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit on September 19,
2021.
You asked the Plan to waive the copayment for an emergency room visit. You say that you were told to come
in for the shot and did not know it was an emergency room. You also say that it was not an emergency. The
Plan denied your request. The Plan says you have been 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 a $60
copayment for an emergency room visit.
You have been asked to pay a $60 copayment for an emergency room visit. The record shows the services were
provided to you in the emergency room. An emergency room visit falls within the Emergency Care benefit category. Please note that although the Hospital was out of network, the Plan has processed your claim at the in-network rate. 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 an emergency room visit on September 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wig (A9282), provided on October 28, 2021.

You asked the Plan to pay for a wig. You say that you need this item. The Plan denied your request. The Plan
says this item is not primarily and customarily used to serve a medical purpose; they are useful in the absence
of illness or injury and they do not replace the function of an internal body organ.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The item at issue in this appeal 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 pay for a wig (A9282), provided on October 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.

You asked the Plan to pre-approve the Vertiflex procedure. You say that this is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered experimental/investigational.

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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed. 

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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to waive the copayment for remote cardiac monitoring provided on March 16,
2021.
You asked the Plan to waive the copayment for remote cardiac monitoring. You say that you have never been
charged in the past and disagree with the charges. The Plan denied your request. The Plan says that you have
been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that enrollees must pay a $0 copayment for diagnostic tests and procedures.
The Plan says you must pay a $35.18 copayment for remote cardiac monitoring. Remote cardiac monitoring
falls within the Outpatient Diagnostic Tests and Therapeutic Services And Supplies benefit category. Based on
the Plan contract, you cannot be asked to pay more than a $0 copayment for diagnostic tests. Therefore, we
decided that the Plan has to waive the copayment for remote cardiac monitoring provided on March 16, 2021.
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.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to waive the copayment for remote cardiac monitoring provided on August 20,
2021.
You asked the Plan to waive the copayment for remote cardiac monitoring. You say that you have never been
charged in the past and disagree with the charges. The Plan denied your request. The Plan says that you have
been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that enrollees must pay a $0 copayment for diagnostic tests and procedures.
The Plan says you must pay a $35.18 copayment for remote cardiac monitoring. Remote cardiac monitoring
falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. Based on
the Plan contract, however, you cannot be asked to pay more than a $0 copayment for remote cardiac
monitoring. Therefore, we decided that the Plan has to waive the copayment for remote cardiac monitoring
provided on August 20, 2021.
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
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound scan services coded 76775 provided on July
30, 2021.
You asked the Plan to pay for the ultrasound scan services. You say that you would like this claim reprocessed
based on the medical records. The Plan denied your request. The Plan says an appropriate modifier was not
billed as required by Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76775
is a column II code to column I code 76706. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for the ultrasound scan services coded 76775 provided on July 30,
2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you missed treatment and were not provided with
medications. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.
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 you do not have daily skilled nursing needs
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled
nursing facility (SNF) setting.
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 skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Acthar injection (J0800).
You asked the Plan to pre-approve Acthar injection. You say that the requested drug is medically necessary.
The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says
self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the
requested drug is not covered under Medicare 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 Acthar injection (J0800). Benefits for Acthar
injection 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis tablet 5mg.
You asked the Plan to pre-approve Eliquis. You say that this medically necessary for the enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare 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 Eliquis tablet 5mg.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 40 routine transportation trips (A0120).
You asked the Plan to pre-approve an additional 40 routine transportation trips. You say that you need the
additional transportation to get to your medical appointments. The Plan denied your request. The Plan says you
have used 16 trips and have 20 trips remaining under your 36-trip limit for your transportation benefit.
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 36 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 an additional 40 routine transportation trips (A0120).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs (A9270) received on September 15, 2021, and September 16, 2021.
You asked the Plan to pay for the drug. You say that this was medically necessary. The Plan denied your request. The Plan says self-administered medications are 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 pay for self-administered drugs (A9270) received on September 15, 2021, and September 16, 2021.