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

We decided that the Plan does not have to waive the coinsurance for the Orthovisc injection you received on November 18, 2020.
You asked the Plan to waive the coinsurance for the Orthovisc injection. You say that you don't believe you owe this amount. The Plan denied your request. The Plan says you were charged this coinsurance 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% coinsurance for Medicare Part B drugs. You have been asked to pay 20% coinsurance for the Orthovisc injection. The Orthovisc injection falls within the Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Orthovisc injection you received on November 18, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for radiation therapy services you received from April 1, 2021, to May 13, 2021.

You asked the Plan to waive the copayments for the radiation therapy services. You say that you cannot believe that you have to pay a copayment for every radiation treatment that you receive.  You said that you didn't have to pay this when you had cancer previously. The Plan denied your request. The Plan says you were charged these copayments 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 a $10 copayment for each for therapeutic radiology service. 

You have been asked to pay a $10 copayment for each of the radiation therapy services. The Schedule of Cost sharing explicitly states that this copayment is charged for each radiation therapy visit. 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 copayments for radiation therapy services you received from April 1, 2021, to May 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic footwear.
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 rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve orthopedic footwear.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for discharge day management (99239) provided on March 31, 2021.
You asked the Plan to pay for discharge day management. You say that this is supported in the records. The Plan denied your request. The Plan says this is not documented.
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, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 30 minutes.
We find that CPT code 99239 is not supported in the medical record. Specifically, the time spent on discharge day management is not documented in the submitted records.. Based on this information, we decided that Medicare rules for coverage of discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for discharge day management (99239) provided on March 31, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya (J3245).
You asked the Plan to pre-approve Ilumya. You say that Ilumya is medically necessary. The Plan denied your request. The Plan says a trial of Remicade OR Inflectra AND Stelara is required before Ilumya can be considered.
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 Ilumya. Our reviewer says that Ilumya is not medically necessary. Our physician reviewer found the record does not show a trial of the plan preferred drugs or any reason they would be unsafe or ineffective 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya (J3245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.

You asked the Plan to pre-approve a portable ventilator. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that ventilators (E0465, E0466, and E0467) are covered under specific conditions. 

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 portable ventilator. Our reviewer says that the services are not medically necessary. Our physician reviewer found the pressure settings ordered for you, with target tidal volume, can be met with the use of a E0471 device. The requested device is being used in the bilevel PAP (positive airway pressure) mode rather than being used as a home ventilator. Products classified as HCPCS code E0466 when used to provide continuous positive airway pressure (CPAP) or bi-level PAP (with or without backup rate) therapy, regardless of the underlying medical condition, shall not be paid in the FSS payment category. The denial of an E0466 home ventilator used with noninvasive interface which is a mechanical ventilator with functionality that exceeds that of an E0470 or E0471 device, is consistent with Medicare regulations. 

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 portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that you have been using the CGM for two years, and it was worked very well for you. You have been able to control your diabetes and no longer have pain due to the finger sticks. You feel that denial would affect your ability to do your job. The Plan denied your request. The Plan says this is not covered for enrollees who do not use 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 administrations. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Orthovisc injection you received on November 30, 2020.
You asked the Plan to waive the coinsurance for the Orthovisc injection. You say that you don't believe you owe this amount. The Plan denied your request. The Plan says you were charged this coinsurance 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% coinsurance for Medicare Part B drugs. You have been asked to pay 20% coinsurance for the Orthovisc injection. The Orthovisc injection falls within the Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Orthovisc injection you received on November 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer.
You asked the Plan to pre-approve the Superion procedure. You say that this procedure is medically necessary. The Plan denied your request. The Plan says this experiment is not proven based on current literature.
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 Superion procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The record indicates that the enrollee has multi-level disease including severe central spinal stenosis at L2-L3 and L3-L4, the levels requested for treatment. The record states the enrollee has not failed physical therapy. The elements of the coverage criteria are not satisfied. 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 Superion procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xeomin injections (J0588).
You asked the Plan to pre-approve the Xeomin injections. You say that Xeomin is medically necessary. The Plan denied your request. The Plan says coverage criteria has 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 the Xeomin injections. Our reviewer says that the injections are not medically necessary. Our physician reviewer found the Food and Drug Administration has stated that the requested drug is indicated for the treatment of upper limb spasticity in adults. In this case, the record indicates that the enrollee has multiple sclerosis. The record indicates that the requested drug is being administered for lower extremity spasticity. The drug is not indicated for this condition 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 Xeomin injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Xeomin injections (J0588).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on April 14, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 50820 and 52332 are not covered.

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, the CPT Code Manual definition of code 50820 is ureteroileal conduit (ileal bladder), including intestine anastomosis (Bricker operation). The definition of code 52332 is cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type).

We find that CPT codes 50820 and 52332 are not supported in the medical record. Specifically, there is no documentation of an ureteroileal conduit, including intestine anastomosis, to support code 50820. There is no documentation of a cystourethroscopy with insertion of indwelling ureteral stent to support code 52332. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on April 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.

You asked the Plan to pre-approve a Vertiflex device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 Vertiflex device. 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 to show safety and efficacy of the device. 

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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on
January 23, 2021.
You asked the Plan to waive the copayment for the ambulance services. The Plan denied your request. The Plan says per the Plan ambulance benefits; the total $240.91 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 a $250 copayment for Ambulance services. You have been asked to pay a $240.91 copayment for the ambulance services. The ambulance services falls within the ambulance services benefit category. The allowable amount for this service is less than the benefit cost share. This means that you have been asked to pay the correct amount based on your contract with the
Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on
January 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on May 28, 2021.
You asked the Plan to pay for hearing aids. You say that the receptionist was told the hearing aids would be
covered by the Plan. The Plan denied your request. The Plan says hearing aids are not covered when provided
by a non-vendor provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when ordered through the Plan's hearing aid provider.
We looked at the file and the Plan's rules. The file shows that the hearing aids were not ordered through the
Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing
aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on
May 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc (J7325).

You asked the Plan to pre-approve Synvisc. You say that this would benefit the enrollee. 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 Synvisc. Our reviewer says that the requirements for coverage of Synvisc have not been met. Our physician reviewer found the Plan requires a trial of drug Orthovisc and Monovisc before they will approve the requested drug. In this case, the patient has not tried and failed Orthovisc and Monovisc. There is no documentation provided indicating that these medications would likely be less effective or 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 Synvisc (J7325).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from March 10, 2021 to April 8, 2021.
You asked the Plan to pay for home health services. You say that the home health services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, a RAP claim has not been submitted for this service. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from March 10, 2021 to April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740).
You asked the Plan to pre-approve the crown. You say that you need two of your teeth to be filled or you will not be able to eat or function without getting your teeth fixed. The Plan denied your request. The Plan says the calendar benefit maximum has been reached.
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, you are limited to up to 2 crowns every calendar year. The record shows that you received a crown on tooth #5 on August 10, 2021, and you received approval for a crown on tooth #12 on September 8, 2021, and your crowns benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.
You asked the Plan to pre-approve the skilled nursing facility services. You say that the skilled nursing facility services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 the skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the patient has stabilized medically and has been receiving skilled services in an inpatient rehabilitation facility (IRF). The member no longer requires daily skilled nursing or skilled therapy services. She could benefit from continued intermittent services at a lower level of care. There is no indication that transfer to a skilled nursing facility is required. 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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit with a physician's assistant in an 
orthopedic surgery office you had on March 5, 2021. 
 
You asked the Plan to waive the copayment for the orthopedic surgery visit. You say that you were told that 
after your surgery, you would have three visits with no copayments.  You said that for this follow-up visit, you 
only saw a nurse who did nothing for you.  You stated that you are on a fixed income and cannot afford this 
copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan 
says that your shoulder surgery occurred on March 10, 2021, five days after the visit in question.  As a result, 
this was not a post-operative visit and therefore the copayment applies. 
 
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 $50 
copayment for specialist visits. You have been asked to pay a $50 copayment for the orthopedic surgery visit. The orthopedic surgery visit falls 
within the specialist visits 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 visit 
with a physician's assistant in an orthopedic surgery office you had on March 5, 2021.