Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Truxima.

You asked the Plan to pre-approve Truxima. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 Truxima. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 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 Truxima have not been met. Therefore, we decided that the Plan does not have to pre-approve Truxima.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular resection prosthesis.
You asked the Plan to pre-approve these services. You say that the prosthesis is needed to restore essential functions. 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 a mandibular resection prosthesis.
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 these services. You say that you check your blood sugars several times per day. The Plan denied your request. The Plan says the criteria for coverage are not 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 treat with insulin three or more times per day or use an insulin pump. 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 pre-approve a continuous glucose monitor (CGM).
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services (G0500) provided December 
8, 2020. 
 
You asked the Plan to pay for the moderate sedation services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says they have insufficient 
documentation to corroborate the services received. 

The Plan must follow Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, 
must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the 
amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, there were no medical records provided in this case. 
Without the medical records, we cannot review to see if the services were accurately described by the codes 
billed. Based on this information, we decided that Medicare rules for coverage of the moderate sedation 
services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation 
services (G0500) provided December 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services (85025, 36415) provided June 24, 2021.
You asked the Plan to waive the copayment for the lab services. You say that the wrong test was performed, and the copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.
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 $6 copayment for lab services provided by an independent laboratory. You have been asked to pay a $6 copayment for the lab services. The test provided falls within the lab services
provided by an independent laboratory 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 lab services (85025, 36415) provided June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services coded as 31641, 31628, and 31624 provided on November 23, 2020.
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed and the payment upheld. The Plan denied your request. The Plan says the claim originally processed incorrectly as the services had already been paid.
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 find that CPT codes 31641, 31628, and 31624 are not supported in the record. Specifically, the record indicates that these codes are an exact duplicate of another claim that has been processed and paid. Additionally, the documentation submitted does not include a description of why modifier -51 was needed.
Per Medicare guidance, failure to report modifier -51 and the unusual circumstances in the narrative portion of the claim will result in a claim rejection. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded as 31641, 31628, and 31624 provided on November 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper interim complete denture. 
 
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 
upper interim complete denture.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 95-year-old female who was hospitalized for a urinary tract infection. While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis. In conclusion, this beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-
network provider. 
 
You asked the Plan to pre-approve physical therapy to be provided by the requested out-of-network provider. 
The Plan denied your request. The Plan says you must receive care from in-network providers with the 
exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care 
cannot be provided with an in-network provider, which requires prior authorization from the Plan. 
 
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 services at issue in this appeal.  
 
We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that 
the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-network 
provider.
Appeal type: Supplemental Benefit
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 used all of the available 50 one-way trips allowed under your contract.
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 50 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tissue debridement provided on May 24, 2021, billed with code 11042.

You asked the Plan to pay for the billed code 11042. You say that this was billed correctly for medically necessary services. The Plan denied your request. The Plan says this code is a Column 2 code in relation to 43762 and cannot be paid without a valid modifier.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that the billed code 11042 is a column II code in relation to column I code 43762. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the tissue debridement provided on May 24, 2021, billed with code 11042.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance services provided November 28, 2020.
You asked the Plan to pay for the air ambulance services. You say that you would like the plan to reconsider their denial. The Plan denied your request.

The Plan says the services rendered were not medically necessary.

The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 

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 pay for the air ambulance services. Our reviewer says that the documentation does not support that the services rendered were medically reasonable or necessary. Our physician reviewer found the enrollee was transported via air ambulance to a different hospital due to not having any available intensive care unit beds. Pulse oxygen was 89% on 100% oxygen, but other vitals were normal. The enrollee had assisted respirations. While the documentation did support that the transferring hospital did not have adequate facilities to provide the medical services needed by the enrollee, the documentation does not support that air medical services were necessary. 

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 air ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the air ambulance services provided November 28, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on April 10, 2021.
You asked the Plan to waive the copayment for the emergency room visit. You say that you could not have to pay a copayment because you were transferred to another hospital to be treated. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency services at an in-network emergency room. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" 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 emergency room visit provided on April 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day reader
You asked the Plan to pre-approve the Freestyle Libre 14-day reader. You say that the enrollee's blood sure is not controlled so he must check it three times a day. However, the enrollee's hands are numb, and it is very hard for him to prick his fingers and check his blood sugar. You say that the requested device is the best choice for him to be able to regularly check his blood sugar and improve his daily life. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for coverage of the requested device.
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 Freestyle Libre 14-day reader have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14-day reader
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the sclerotherapy services and duplex scan of the lower extremity veins provided on November 8, 2018.

You asked the Plan to pay for the sclerotherapy services and duplex scan of the lower extremity veins. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services rendered were not medically necessary.

The Plan follows Medicare rules. Medicare rules say that sclerotherapy and duplex scans are 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 pay for the sclerotherapy services and duplex scan of the lower extremity veins. Our reviewer says that the documentation does not support that the services rendered were medically reasonable or necessary. Our physician reviewer found the enrollee is status post multiple endovenous ablative procedures. It is unclear when these were performed and what the response to those treatments were. It is not possible to attribute the patient's current symptoms/findings to varicose veins as there is no physical examination documented that describes an ulcer and no documentation of arterial perfusion. The documentation does not suggest an emergent situation for which there was no time to undergo preauthorization. Furthermore, there is no duplex report provided demonstrating reflux in tributary veins in the absence of truncal reflux and the absence of deep venous obstruction. The clarity of the overall process was not enhanced by documentation that a liver biopsy was performed for left leg varicose veins and patient instructions for paracentesis. 

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 sclerotherapy services and duplex scan of the lower extremity veins have not been met. Therefore, we decided that the Plan does not have to pay for the sclerotherapy services and duplex scan of the lower extremity veins provided on November 8, 2018.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the transthoracic echocardiography with 
contrast (C8929) provided on June 23, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $100 
copayment for in-network diagnostic tests and procedures provided at an outpatient hospital.  

You have been asked to pay a $100 copayment for the in-network diagnostic test provided at an outpatient 
hospital. 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 transthoracic echocardiography with 
contrast (C8929) provided on June 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the cranial prosthesis (wig) and associated sales tax purchased on May 18, 2021.

You asked the Plan to pay for the wig and sales tax. You say that you have hair loss due to cancer treatment. You were told that this is covered by the Plan and feel this was denied in error. The Plan denied your request. The Plan says Medicare does not provide coverage for wigs in this situation. The Plan also does not have a supplemental benefit which covers this.

Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules.

In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue.

As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the cranial prosthesis (wig) and associated sales tax purchased on May 18, 2021.