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

 We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).  You asked the Plan to pre-approve the therapeutic CGM. You say that this device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 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 the therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a home ventilator.  You asked the Plan to pre-approve ventilator. You say that your physician and you both agree that a ventilator is valuable to your health. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the needed positive airway pressure (PAP) therapy can be provided by a bi-level positive airway pressure (BiPAP) device with average volume assured pressure support (AVAPS) mode; therefore, a ventilator is not covered.  The Plan follows Medicare rules. Medicare rules state that ventilators used to provide continuous or bi-level positive airway pressure therapy 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 ventilator. Our reviewer says that you do not meet the Medicare criteria for a ventilator. Our physician reviewer found you have chronic obstructive pulmonary disease (COPD) and were recently hospitalized. You improved with bi-level positive airway pressure (BiPAP) and other treatments. An arterial blood gas test showed carbon dioxide (CO2) retention, but this has not been repeated when you are stable as an outpatient. BiPAP has not been tried at home. Average volume assured pressure support (AVAPS) mode of support can be provided by BiPAP, and Medicare does not cover a home ventilator when used as a BiPAP.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
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 these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at 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. On review of the available records, you have multiple fractures from a motor vehicle crash and are medically stable. With your comorbid conditions being stable, you do not need physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute or complex rehab nursing needs noted in the record. At the current functional level, you do not need 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 physical and occupation therapy, your rehabilitation needs can be safely met in an alternate and lower intensity setting. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.  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: 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 rehabilitation 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: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Brovana.  You asked the Plan to pre-approve Brovana. The Plan denied your request. The Plan says you have not tried and failed Perforomist.   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 Brovana. Our physician reviewer found that the Plan requires a trial of Perforomist before they will approve the requested drug. In this case, you have not tried and failed the required drug. There is no documentation provided indicating that the plan's required drug would likely be less effective or likely have adverse effects.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Brovana have not been met. Therefore, we decided that the Plan does not have to pre-approve Brovana.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eyeglasses (V2020, V2103, V2744, V2750, V2784) provided on September 24, 2021.  You asked the Plan to pay for the eyeglasses. You say that you thought you last had eyeglasses provided over a year ago and were eligible for new services. The Plan denied your request. The Plan says your benefit covers routine eyewear once every two years. You previously purchased eyeglasses in October of 2020, which is less than two years before the date in question.  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. The Plan covers these services once every two years.  We looked at the file and the Plan's rules. The record shows that it has been less than two years since you last used your supplemental eyewear benefit. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2020, V2103, V2744, V2750, V2784) provided on September 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion services coded 99601 and 99602 provided on May 20, 2021.  You asked the Plan to pay for the home infusion services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says these codes are not eligible for payment under 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.  We looked at the file and Medicare rules. In this case, these codes have a Status Code of "I" under the Physician Fee Schedule indicating they are not valid for Medicare purposes.  Based on this information, we decided that Medicare rules for coverage of the home infusion services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion services coded 99601 and 99602 provided on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit provided on April 9, 2021, by an OON provider.  You asked the Plan to pay for an office visit. You say that you thought prior authorization was obtained prior to services rendered. The Plan denied your request. The Plan says there was no prior authorization obtained for the enrollee to receive services from an out-of-network provider.  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 an office visit provided on April 9, 2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the wound care supplies provided on August 4, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the wound care supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says you must obtain items through a Plan provider.  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 the wound care supplies provided on August 4, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve treatment with Humulin R (J1815) to be used in an insulin pump.  You asked the Plan to pre-approve Humulin R. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for coverage have not been met because the requested drug as prescribed is not being used for a medically accepted indication.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Humulin R. Our reviewer says that the requested drug is medically reasonable and necessary in this case. Our physician reviewer found that, although rapid-acting insulin is usually used in pumps in recent history, regular insulin has been used in pumps in the past and still has some uses. These include patients with gastroparesis where digestion and blood glucose rise post-meal occurs more slowly and in patients with insulin autoantibodies where insulin effects can be delayed and are hard to predict. You have used this method and had good results with the enrollee; the requested use of Humulin R should be continued and followed closely.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Humulin R have been met. Therefore, we decided that the Plan has to pre-approve treatment with Humulin R (J1815) to be used in an insulin pump.   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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an endosteal implant, bone replacement graft, implant supported porcelain/ceramic crown, and cone beam imaging.  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 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 pre-approve an endosteal implant, bone replacement graft, implant supported porcelain/ceramic crown, and cone beam imaging.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (G0482) provided on July 8, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for drug testing. You say that you performed the test at the request of the ordering physician, and this test is deemed medically necessary for the treatment and management of this patient. The Plan denied your request. The Plan says the service was performed by a non-participating provider and the service was not authorized by the Plan. The Plan also says that the service was ordered by a non-participating provider.  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 drug testing (G0482) provided on July 8, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (G0480) provided on September 16, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for drug testing. You say that you were not aware of the requirement of obtaining a prior authorization, specifically for this member's plan type at the time of rendering services. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in a participating facility. The Plan also say that they have also determined that these services are not urgent or emergent, nor were they approved in advance.  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 drug testing (G0480) provided on September 16, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the physical therapy provided on June 17, 2021, to September 10, 2021.  You asked the Plan to waive the copayment for the physical therapy. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.  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 for each Medicare covered outpatient rehabilitation services.   You have been asked to pay $20 for each physical therapy session. This service falls within the outpatient rehabilitation 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 the physical therapy provided on June 17, 2021, to September 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve FreeStyle Libre continuous glucose monitoring sensors.  You asked the Plan to pre-approve FreeStyle Libre continuous glucose monitoring sensors. You say that this is medically necessary. The Plan denied your request. The Plan says that you are not on insulin. The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of FreeStyle Libre continuous glucose monitoring sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve FreeStyle Libre continuous glucose monitoring sensors.
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 records provided support the need for care in an IRF. You say that the enrollee's ability to ambulate and talk is limited. You say that denying IRF care could jeopardize the enrollee's ability to recover maximum function. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF.  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 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. The enrollee was admitted for gastrointestinal bleeding, anemia, respiratory failure, and renal failure. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that the 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.