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

 We decided that the Plan does not have to pre-approve endocrinology services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve OON services. You say that the requested provider is closer to home. The Plan denied your request. The Plan says in-network providers are available.  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 endocrinology services at issue in this appeal.  We were able to confirm that the Plan has contract providers located within reasonable distance and travel time from your home who can provide the requested services.   We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve endocrinology services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.

You asked the Plan to pre-approve the requested item. You say that you need portable oxygen when you travel. The Plan denied your request. The Plan says Medicare does not cover oxygen equipment for travel or specific use outside of the home.

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 file shows that you have a home oxygen concentrator and portable oxygen tanks. The oxygen equipment you have serves the same purpose as the requested item. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Protonix 40 mg tablet.  You asked the Plan to pre-approve Protonix. You say that this drug is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.  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 Protonix 40 mg tablet.   Benefits for Protonix 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 Ondansetron tablets.

You asked the Plan to pre-approve Ondansetron tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Ondansetron tablets are not covered under the enrollee's Medicare Part B benefit as prescribed for the enrollee in this case.

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 Ondansetron tablets.

Benefits for Ondansetron tablets 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cologuard testing (G0121).

You asked the Plan to pre-approve Cologuard testing. You say that you cannot tolerate a colonoscopy. 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 the Cologuard test is covered once every three years for Medicare beneficiaries that are asymptomatic.

We looked at the file and Medicare rules. The record shows that you are currently not symptomatic as you have gastrointestinal pain and other symptoms. Based on this information, we decided that Medicare rules for coverage of Cologuard testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Cologuard testing (G0121).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laparoscopy with gastric bypass and Roux-en-Y gastroenterostomy.

You asked the Plan to pre-approve bariatric surgery. You say that this surgery is important to improve your health and quality of life and is really necessary. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because your body-mass index (BMI) is less than 35 and repeat bariatric surgery is generally not necessary.

The Plan must follow Medicare rules. Medicare rules say that bariatric surgery such as laparoscopic Roux-en-Y gastric bypass is covered for Medicare beneficiaries who have a body-mass index greater than or equal to 35. 

We looked at the file and Medicare rules. The record shows that your body-mass index (BMI) is less than 35. Based on this information, we decided that Medicare rules for coverage of bariatric surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve laparoscopy with gastric bypass and Roux-en-Y gastroenterostomy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided from April 28, 2021, to August 28, 2021.  You asked the Plan to waive the coinsurance for DME and related supplies. You say that you need the equipment due to having had the coronavirus. 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 DME and related supplies.   You received DME and related supplies from April 28, 2021, to August 28, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. Please see the chart below.   Date of Service Service Allowed Amount Amount You Owe 4/28/2021 DME and Related Supplies $97 $19.40 5/28/2021 DME and Related Supplies $116 $23.20 6/28/2021 DME and Related Supplies $116 $23.20 7/28/2021 DME and Related Supplies $19 $3.80 8/28/2021 DME and Related Supplies $19 $3.80  The total amount you owe is: $73.40.   You have been asked to pay the total coinsurance amount of $73.40 for DME and related supplies. DME and related supplies fall within the DME and related supplies 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 DME and related supplies provided from April 28, 2021, to August 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to provide coverage for additional routine transportation trips.  You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your request. The Plan says you have exhausted all 24 of your trips according to your Plan benefits.  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 24 one-way 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 provide coverage for additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a labial veneer (porcelain laminate) (D2962) and a labial veneer (resin laminate) (D2960) provided by a participating provider.  You asked the Plan to pre-approve labial veneers. You say that you feel like these services are medically necessary. The Plan denied your request. The Plan says the services being requested are not covered benefits.  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 labial veneer (porcelain laminate) (D2962) and a labial veneer (resin laminate) (D2960) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the occlusal guard.  You asked the Plan to pre-approve the occlusal guard. You say that your dentist ordered the night guard because you suffer from dental bruxism which caused deep wear of your upper and lower teeth. You say that this is a necessity not a luxury and you are hoping for a fair solution. The Plan denied your request. The Plan says the service is not a covered benefit.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.    Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the occlusal guard.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.  You asked the Plan to pre-approve the compression stockings. You say that you have pulmonary embolism and feel these items are medically necessary. 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 A6533 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 A6533.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor.  You asked the Plan to pre-approve the continuous glucose monitor.. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria.  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 continuous glucose monitor. have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment without transport (A0998) provided on June 12, 2021.  You asked the Plan to pay for ambulance response without transport. You say that your family called the ambulance, and you were ultimately taken to the hospital by your family after the ambulance arrived on your way out. You say you were not feeling well and would have used the ambulance transportation if you knew these services would not be covered otherwise. The Plan denied your request. The Plan says the ambulance benefit is a transportation benefit. When no transportation is provided, there is no payable service.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on June 12, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without transport (A0998) provided on June 12, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the inpatient hospitalist services provided on June 11, 2021, by Vladmir Stamoran, MD.  You asked the Plan to pay for the inpatient hospitalist services. You say that these two visits were from physicians of different specialties, on Internal Medicine and one Gastroenterology. The Plan denied your request. The Plan says that these physicians are both internal medicine providers and work for the same group practice.  The Plan must follow Medicare rules. Medicare rules say that physicians of the same specialty may not both bill for inpatient evaluation and management services on the same date. However, if they are of different specialties, both may be paid.  In this case, though the taxonomy associated with the physicians' National Provider Identification (NPI) number is the same, the records clearly support that the billing physician is working for the hospitalist service and the other physician for gastroenterology. Since the record supports different specialties and different aspects of patient care, both physicians may be paid for this date of service. Therefore, we decided that the Plan has to pay for the inpatient hospitalist services provided on June 11, 2021, by Vladmir Stamoran, MD.   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 pneumatic compression device (E0651, E0667) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the pneumatic compression device. You say that the items are medically necessary. The Plan denied your request. The Plan says there are in-network suppliers available.  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 at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0651, E0667) to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance services provided on June 9, 2020.  You asked the Plan to pay for ambulance services. You say that the services at issue were a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for payment have not been met because the claim was not filed timely.  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  The record shows that a claim for ambulance services was not filed until June 14, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for ambulance services provided on June 9, 2020.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an EGD provided on May 27, 2021.  You asked the Plan to waive the copayment for an EGD. You say that you disagree with the charges because the provider told you that you would not owe a 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 $225 copayment for outpatient surgery, including services provided at ambulatory surgical centers.   You received an EGD on May 27, 2021, at an ambulatory surgical center. An EGD is considered a diagnostic surgical procedure. Therefore, you are responsible to pay the $225 copayment.  You have been asked to pay a $225 copayment for an EGD. An EGD 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 copayment for an EGD provided on May 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Retacrit (Q5106).  You asked the Plan to pre-approve Retacrit. You say that this drug is medically reasonable and 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. 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 Retacrit. Our reviewer says that the requested drug is not medically reasonable and necessary for the enrollee's condition. Our physician reviewer found the provider requested Retacrit to treat the enrollee's anemia of myelodysplastic syndrome. The review indicates that the drug/regimen is not being prescribed for a medically-accepted indication. The documentation does not support that the member has: a serum erythropoietin level of 500 international units/L or less. Members with an erythropoietin level greater than this level are unlikely to respond to erythropoiesis stimulating agents therapy. The review indicates that the documentation does not support that Retacrit is medically reasonable and necessary for the patient. The documentation does not support that Retacrit is safe and effective for the patient.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit (Q5106).
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve non-emergency, non-ambulance transportation (A0100) to your local supermarket.  You asked the Plan to pre-approve non-emergency, non-ambulance transportation. You say that you do not have transportation and the supermarket is very far from your house. The Plan denied your request. The Plan says rules for coverage for routine transportation have not been met.  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 routine transportation to Plan-approved locations through contracted suppliers.   We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, there is no documentation of an eligible chronic condition. Based on the documentation provided, we cannot determine that you are eligible for transportation for non-medical needs. Therefore, we decided that the Plan does not have to pre-approve non-emergency, non-ambulance transportation (A0100) to your local supermarket.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for hand surgery.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the requested service is available within the primary network.

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 an out-of-network referral for hand surgery.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says that the requested admission to a LTACH does not meet criteria.

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. We requested medical records from the Plan on December 13, 2021. We did not receive medical records or a response from the Plan. Therefore, we decided that the Plan has to pre-approve long term acute care hospital (LTACH) services.

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.