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

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (K0554).

You asked the Plan to pre-approve a Freestyle Libre. You say that the requested item is a medical necessity for you. 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 you do not use insulin with at least three daily injections.

Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (K0554).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided August 4, 2021.  

You asked the Plan to pay for the comprehensive oral exam. You say that you wanted a second opinion. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 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. The Plan covers the comprehensive oral exam once every three years.  

We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral exam was previously covered on May 11, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided August 4, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 We decided that the Plan has to pre-approve an office consultation to be rendered by the out-of-network (OON) provider.  You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says that there are in-network providers available to render the requested service.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not provided the Evidence of Coverage booklet which states the contractual coverage policy. Therefore, we decided that the Plan has to pre-approve an office consultation to be rendered by the out-of-network (OON) provider.   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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a knee orthosis (L1851).  You asked the Plan to pre-approve a knee orthosis. You say that you need this because you are in pain. The Plan denied your request. The Plan says the requirements for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that a knee orthosis coded as L1851 is covered if the beneficiary has had recent injury to or a surgical procedure or for a beneficiary who is ambulatory and has knee instability.  We looked at the file and Medicare rules. The records show that your knee is stable and do not document a recent injury or surgery. Based on this information, we decided that Medicare rules for coverage of a knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis (L1851).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a breast biopsy provided on May 26, 2021.

You asked the Plan to waive the copayment for a breast biopsy. You say that the biopsy was unnecessary. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $200 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. 

The enrollee has been asked to pay a $200 copayment for a breast biopsy. A breast biopsy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.

Therefore, we decided that the Plan does not have to waive the copayment for a breast biopsy provided on May 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention (78227).  You asked the Plan to pre-approve Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention (78227). You say that the requested Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention (78227) is medically necessary. The Plan denied your request. The Plan says the requested Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention (78227) 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 Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention (78227). Our reviewer says that the requested Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention (78227) is not medically necessary. Our physician reviewer found the record indicates that the enrollee has gastroesophageal reflux. The record does not indicate the results of an ultrasound or laboratory tests to assess liver function. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.  The requested service is not 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 Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention (78227) have not been met. Therefore, we decided that the Plan does not have to pre-approve Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention (78227).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablations (RFAs).

You asked the Plan to pre-approve radiofrequency ablations. You say that the procedures done in the past were done on one side, but this request is for bilateral radiofrequency ablations. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee has already exhausted the 2 covered sessions per spinal region within 12 rolling months.

The Plan must follow Medicare rules. Medicare rules say that no more than 2 radiofrequency sessions will be covered per rolling 12 months. 

We looked at the file and Medicare rules. The enrollee previously received covered radiofrequency sessions on May 3, 2021 and May 11, 2021; therefore, the benefit limit of 2 radiofrequency sessions per rolling 12 months is exhausted at this time. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablations have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablations (RFAs).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Injectafer (J1439).  You asked the Plan to pre-approve Injectafer. You say that the hospital always has Injectafer on hand. The Plan denied your request. The Plan says step therapy requirements have not been met.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Injectafer. Our reviewer says that the requirements for coverage of Injectafer have not been met. Our physician reviewer found the Plan requires a trial of two preferred agents, which are Ferrlecit, Infed, and Venofer, before they will approve the requested drug. The records do not indicate the enrollee has tried two of these drugs or that the enrollee has a contraindication to these drugs.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer (J1439).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve wireless capsule endoscopy.  You asked the Plan to pre-approve wireless capsule endoscopy. You say that the enrollee had a normal esophagogastroduodenoscopy (EGD) but an abnormal computed tomography (CT) scan. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is no documented small bowel bleeding that was undetected by colonoscopy or upper endoscopy.  The Plan follows Medicare rules. Medicare rules state that a wireless capsule endoscopy is only covered for certain indications.  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 wireless capsule endoscopy. Our reviewer says that the enrollee does not meet the Medicare criteria for a wireless capsule endoscopy. Our physician reviewer found the enrollee underwent upper endoscopy that demonstrated an oozing peptic ulcer. Computed tomography (CT) scan demonstrated thickened loops of small bowel. The records do not show the presence of a covered indication for the requested test.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of wireless capsule endoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve wireless capsule endoscopy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a surgical extraction (D7140).  

You asked the Plan to pre-approve a surgical extraction. You say that you were advised by your provider to see a specialist as you need a lot of work including a surgical extraction. The Plan denied your request. The Plan says the dental services requested are not covered under your Plan.  

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 a surgical extraction (D7140).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compression devices (E0673) provided on April 12, 2021.  

You asked the Plan to pay for pneumatic compression devices. You say that the items at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for durable medical equipment have not been met.  

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   

The record does not contain a valid proof of delivery for the supplies provided in this case. The document provided as proof of delivery does not show that any item coded E0673 was provided to the enrollee in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for pneumatic compression devices (E0673) provided on April 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug test (G0482) rendered by the out-of-network (OON) provider on July 7, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the drug test (G0482) rendered by the out-of-network (OON) provider on July 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with an electro-acupuncture device.  You asked the Plan to pre-approve electro-acupuncture. You say that the requested service is a medical necessity for you. The Plan denied your request. The Plan says the requested service is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that electro-acupuncture devices used for stimulation of auricular acupuncture points are non-covered.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of electro-acupuncture have not been met. Specifically, the request is for use of an electro-acupuncture device. Therefore, we decided that the Plan does not have to pre-approve treatment with an electro-acupuncture device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a tendon sheath injection provided on January 27, 2021.

You asked the Plan to waive the copayment for a tendon sheath injection. You say that you disagree with the surgery charges and would like the claims to be reprocessed. 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 $390 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. 

You have been asked to pay a $390 copayment for a tendon sheath injection. A tendon sheath 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 tendon sheath injection provided on January 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve OTC benefit for the first quarter of the year 2021.  You asked the Plan to pre-approve OTC benefit for the first quarter of the year 2021. The Plan denied your request. The Plan says OTC benefits of the first trimester are not cumulative.  The Plan contract offers a supplemental OTC benefit. The benefit will pay the item up to the quarterly coverage limit. The amounts must be used in full as they do not accumulate from quarter to quarter.  We looked at the file and Medicare rules. The file shows that the benefit will pay the item up to the quarterly coverage limit. The amounts must be used in full as they do not accumulate from quarter to quarter. Therefore, we decided that the Plan does not have to pre-approve OTC benefit for the first quarter of the year 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a seat lift chair.  You asked the Plan to pre-approve a seat lift chair. You say that you are in a lot of pain and have trouble getting up. The Plan denied your request. The Plan says the requirements for coverage have not been met.  The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met.  We looked at the file, and Medicare rules. The submitted records show that you are not completely unable to stand up from a regular armchair or any chair in the home. Based on this information, we decided that Medicare rules for coverage of a seat lift chair have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a microprocessor knee (L5845, L5828, L5856) and a specialized prosthetic cover (L5964).  You asked the Plan to pre-approve a microprocessor knee and a specialized prosthetic cover. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage have not been met.  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 a microprocessor knee and a specialized prosthetic cover. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation that the enrollee meets criteria for a microprocessor knee. Medical records from the enrollee's provider do not clarify that the enrollee is unable to use a mechanical K3 knee rather than the requested microprocessor knee. There is no documentation that the enrollee meets criteria for a specialized cover. Records do not document that the enrollee is exposed to such harsh conditions or environments that use of the custom shaped protective cover (L5705) would be precluded.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a microprocessor knee and a specialized prosthetic cover have not been met. Therefore, we decided that the Plan does not have to pre-approve a microprocessor knee (L5845, L5828, L5856) and a specialized prosthetic cover (L5964).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Synvisc (J7325).  You asked the Plan to pre-approve Synvisc. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been met.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Synvisc. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy rules, as outlined by the Plan, require that these alternatives be trialed first. The provided documentation does not outline contraindications or reasons these medications were not considered or that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Synvisc (J7325).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve recode therapy to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve recode therapy. You say that you are very comfortable under this provider's care. You trust her and trust the recode process. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered. Services by a licensed massage therapist is not covered.  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 recode therapy to be provided by an out-of-network (OON) provider.