Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.

You asked the Plan to pre-approve home health services. You say that the requested home health services are medically necessary. The Plan denied your request. The Plan says the home health services are not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 home health services. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found the documentation does not support that the enrollee requires skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The reviewer found that the enrollee does not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve their condition, perform a maintenance program to maintain their condition and/or prevent deterioration. The reviewer also found that the enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Therefore, the reviewer found that the requested home health services are not medically 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 home health services have not been met. Specifically, the file does not indicate that the enrollee requires skilled nursing services or skilled rehab services to provide treatment that is medically necessary. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve physical therapy services. 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. None of these exceptions apply and there is no gap in the 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 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 services to be provided by the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651, E0669) to be
provided by an OON provider.

You asked the Plan to pre-approve a pneumatic compression device. You say that there are no other providers
that can service this patient with this particular device in the patient's geographical area. The Plan denied your
request. The Plan says this provider is an out-of-network (OON) provider and while this OON provider claims
that their product is unique, there is no authoritative medical literature or technology review that demonstrates
that any brand of E0651 is clinically superior to any other brand. The Plan also says they have confirmed that
there are in-network providers available that can supply this device.

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
a pneumatic compression device (E0651, E0669) to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Intracept procedure.

You asked the Plan to pre-approve Intracept procedure. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Intracept 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 diagnoses of spondylosis without myelopathy or radiculopathy, lumbar region and vertebrogenic low back pain. The requested intracept procedure is experimental. More research is needed. Therefore, the enrollee does not meet criteria for the requested services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine (90750) provided on September 22, 2021.

You asked the Plan to pay for the shingles vaccine. You say that you would like reconsideration because you received the first dose of the shingles vaccine. The Plan denied your request. The Plan says per Medicare rules, some vaccines such as those for Shingles, Tdap, and foreign travel are Part D drugs and do not meet Medicare Part B coverage rules, and therefore are not covered by your plan.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine (90750) provided on September 22, 2021.

Benefits for the shingles vaccine 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve paravertebral facet joint injections for the enrollee.
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied
your request. The Plan says there are radicular symptoms and the pain is not axial.
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 injections. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found that in this case, the enrollee has the presence of radiculopathy. The pain is associated with
radiculopathy and there in no documentation provided indicating that the facet joint is the main source of pain.
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 injections have not been met. Therefore, we decided that the Plan does not
have to pre-approve paravertebral facet joint injections for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit for the enrollee.
You asked the Plan to pre-approve Procrit. You say that this is medically necessary for the enrollee. The Plan
denied your request. The Plan says that the member does not have a documented hemoglobin of 10 g/dl or
below.
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 Procrit. Our reviewer says that Procrit
is not medically reasonable and necessary. Procrit is not FDA-approved for the enrollee's diagnosis. There was
no hemoglobin is provided. The use of Procrit is not supported by one of the major drug compendia or by
clinical research that appears in a Centers for Medicare & Medicaid Services approved medical journal. Our
physician reviewer found that the enrollee's condition does not meet criteria for Procrit.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to
pre-approve Procrit for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the gauze, non-impregnated, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing (A6219) provided August 9, 2021.
You asked the Plan to pay for the medical supplies. You say that the claim should have been paid and you request a reconsideration of its denial. The Plan denied your request. The Plan says payment for this service/supply/device is not allowed because it was included in the facility claim.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that the medical supplies was used in a SNF or hospital. Payment for this supplies would have been included under the facility claim. Payment for this service is the responsibility of the SNF. Therefore, we decided that the Plan does not have to pay for the gauze, non-impregnated, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing (A6219) provided August 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cyclobenzaprine.
You asked the Plan to pre-approve Cyclobenzaprine. The Plan denied your request. The Plan says this drug is
not eligible for coverage under the Part B 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 Cyclobenzaprine.
Benefits for Cyclobenzaprine 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a primary care provider visit provided on
August 10, 2021.
You asked the Plan to waive the copayment for the primary care provider. You say that the services should be
covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services
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 $5
copayment for Physician/Practitioner services, including doctor's office visits.
You have been asked to pay a $5 copayment for the primary care provider. Primary care visits fall within the
Physician/Practitioner services, including doctor's office 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 a primary care provider visit provided on August 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on September 16, 2021.
You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says 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 Plan says that the Plan has 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 did not pre-approve the
physical therapy services. We found no exception that would require the Plan to pay for these services.
Therefore, we decided that the Plan does not have to pay for physical therapy services provided on
September 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued physical therapy.
You asked the Plan to pre-approve continued physical therapy. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee has already had 22 physical therapy visits which should meet the enrollee's needs, so additional visits are not necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 continued physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has been approved for 22 physical therapy visits, 4 of which were to assist with a home exercise program. The enrollee reported compliance with the new home exercise program and continued slow but steady progress toward long-term goals. The details of the physical therapy treatments do not support the medical necessity for continued therapy sessions. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve continued physical therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from
July 13, 2021, to August 11, 2021.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not be
responsible for the copayment after eight days. The Plan denied your request. The Plan says the enrollee was
not liable for a second procedure and the proper copayment was applied to the first six days.
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 $300
copayment for In-network Medicare-covered hospital admission/stay days 1-6. The total copayment amount
was $1800 ($300 a day x 6 days).
You have been asked to pay a $1800 copayment for an inpatient hospital stay. The inpatient hospital stay falls
within Inpatient hospital 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 an inpatient
hospital stay provided from July 13, 2021, to August 11, 2021.
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 a continuous glucose monitor. You say that this is medically necessary. 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 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 a
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from
March 18, 2021, to March 24, 2021.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the copayment should
be waived because of coronavirus (COVID-19). The Plan denied your request. The Plan says the COVID
benefit oversight end date for waiving the cost share ended prior to the date(s) of service. The proper
copayment 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 $295
copayment for Medicare-covered hospital stay Days 1-6: $295 copayment per day and Days 7-90: $0
copayment per day with the day before you are discharged is your last inpatient day. From March 18, 2021, to
March 24, 2021 the total copayment was $1,770 ($295 copayment x 6 days).
You have been asked to pay a $1,770 copayment for an inpatient hospital stay. An inpatient hospital stay falls
within the Inpatient hospital 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
an inpatient hospital stay provided from March 18, 2021, to March 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity.
You asked the Plan to pre-approve Evenity. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
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 Evenity. Our reviewer says that the
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer
found the enrollee has been diagnosed with severe osteoporosis with a bone scan score of -3.4 of the left radius.
The documentation does not support that the enrollee has had a trial and failure of two oral bisphosphonates or
an oral bisphosphonate and intravenous (IV) zoledronic acid or Prolia. The documentation does not support
that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to
pre-approve Evenity.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99334) debridement of nails by any method (11721) provided on March 22, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that the assisted living facility is responsible to obtain prior authorization for all of their patients, which should also cover for the medical treatments provided by this doctor. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 domiciliary or rest home visit (99334) debridement of nails by any method (11721) provided on March 22, 2021 by an out-of-network (OON) provider.