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

We decided that the Plan does not have to reduce the cost share for a Humalog injection.
You asked the Plan to reduce the cost share for Humalog. The Plan denied your request. The Plan says a tier cost sharing exception is not allowed under the medical benefit.
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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for Humalog. Humalog falls within the Medicare Part B prescription 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 reduce the cost share for a Humalog injection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient office visits and Pembrolizumab (Keytruda) every 21 days for the additional 21 months.
You asked the Plan to pre-approve the outpatient office visits and Keytruda for the additional 21 months. You say that the enrollee has been on Keytruda since March 11, 2020 with a good response. You also say that Keytruda is medically necessary. The Plan denied your request. The Plan says the requested Keytruda infusion is not medically necessary for the enrollee's condition. The Plan also says that the authorization cannot be extended out for a full 2 year period because the enrollee requires a CT scan every 3 months to assure there is no progression of the disease.
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 outpatient office visits and Keytruda for the additional 21 months. Our reviewer says that outpatient office visits and Keytruda for the additional 21 months are not medically necessary. Our physician reviewer found given the reported approval of Keytruda through November 9, 2020, additional pre-authorization is not appropriate until an interval assessment is completed, and disease progression is assessed. The additional twenty months of therapy are not currently shown to be medically necessary or reasonable. 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 outpatient office visits and Keytruda for the additional 21 months have not been met. Therefore, we decided that the Plan does not have to pre-approve outpatient office visits and Pembrolizumab (Keytruda) every 21 days for the additional 21 months.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically necessary. The Plan denied your request. The Plan says you can receive same services at the current level of care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found you do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Botox. 
 
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 that the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has spastic hemiplegia 
following a stroke. During a recent telemedicine visit, it was noted that the enrollee had previously received 
botulinum injections and done well with them.  A physical examination could not be conducted. Allowing for 
the limitations of telemedicine, it is my opinion that the records do show prior good response to botulinum 
injections. The documentation supports that Botox is reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve Botox.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional 9 Eylea injections, additional 9 
intravitreal injections of a pharmacologic agent, and additional 9 scans of computerized ophthalmic diagnostic 
imaging to be provided by you, an OON provider. 
 
You asked the Plan to pre-approve the Eylea injections, intravitreal injections of a pharmacologic agent, and 
scans of computerized ophthalmic diagnostic imaging. You say that you are the only retinal specialist in the 
area for these procedures. You also say that you have almost completed your credentialing with the Plan. The 
Plan denied your request. The Plan says you are a non-contracted provider with the enrollee's health plan. The 
Plan also says that non-emergency services are not covered when they are provided by a non-contracted 
provider, and there are contracted providers who can render the services. 
 
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. The Plan approved 3 visits in order to give 
the enrollee time to establish with a participating provider, or allow you to complete credentialing. 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 the additional 9 Eylea injections, additional 9 
intravitreal injections of a pharmacologic agent, and additional 9 scans of computerized ophthalmic diagnostic 
imaging to be provided by you, an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crown-porcelain/ceramic substrate, tooth 27 (D2740) core buildup including any pins, tooth 27 (D2950).
You asked the Plan to pre-approve the dental services. You say that the records should support the necessity of the service in dispute. The Plan denied your request. The Plan says the requested treatment is not medically necessary.
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. The Plan covers the dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided x-ray and photo are not of high quality and there is a questionable amount of decay present on the tooth, but it also appears to extend to the bony crest. Given the provided documentation, it is not possible to determine the extent of the decay and its possible impingement on the attachment which would prevent placement of a crown without further intervention. There is no current medical necessity found for the requested procedures. If diagnostic quality x-rays are submitted that clearly show the extent of the claimed damage and decay then the request can be reassessed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve crown-porcelain/ceramic substrate, tooth 27 (D2740) core buildup including any pins, tooth 27 (D2950).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a lumbosacral interlaminar epidural injection.

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 that the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has a four year history of bilateral low back pain with radiation to the right leg and foot. The pain is rated at 10 out of 10. Treatment has consisted of medical therapy including opiates, previous epidural steroid injection (ESI) therapy and physical therapy. The requested injection is the standard of care for low back pain with radiculopathy that has failed conservative therapy. The injection is therefore not reasonable or 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 these services have been met. Therefore, we decided that the Plan has to pre-approve a lumbosacral interlaminar epidural injection. 

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 power operated vehicle.
You asked the Plan to pre-approve the vehicle. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 vehicle. Our reviewer says that the requested vehicle is not medically reasonable or necessary. Our physician reviewer found you have a personal mobility deficit, but the documentation does not indicate that it impairs participation in MRADLs in the home. Your mobility deficit is helped by the use of a manual wheelchair or walker due to right hand/wrist pain and weakness per the evaluation. It is not clear why you cannot use a cane in the left-hand which 4+/5 strength, normal range of motion, and coordination. You can ambulate with low fall risk, controlled gait with excessive time 75 feet in the home without an assistive device. You appear to have cognitive function intact to operate the vehicle. Your home is not wheelchair-accessible; therefore, it is not clear that you could use the vehicle safely. 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 vehicle have not been met. Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (PWC).
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 medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a PWC is covered when specific criteria are met. 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 these services. Our reviewer says that you do not meet the criteria for coverage. Our physician reviewer found the submitted records show that you have a mobility limitation that impairs your ability to participate in one or more mobility-related activities of daily living (MRADLs). The mobility limitation is able to be safely resolved by the use of an appropriately-fitted manual wheelchair; therefore, the PWC is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (PWC).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a lumbosacral transforaminal epidural steroid injection (TFESI). 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a TFESI is covered when specific criteria are 
met. 
 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has a four year history of 
bilateral low back pain with radiation down the posterior aspect of the right leg to the foot. The pain is rated at 
10 out of 10. Treatment has consisted of medical therapy including opiates, previous epidural steroid injection 
(ESI) therapy and physical therapy. The requested TFESI is the standard of care for low back pain with 
radiculopathy that has failed conservative therapy and is reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve a lumbosacral transforaminal epidural steroid injection (TFESI).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and two resin-based composites provided on March 12, 2020.
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and resin-based composites. You say that you did not cancel your dental plan. The Plan denied your request. The Plan says your dental and vision optional supplemental benefits were terminated on December 31, 2019. The Plan also says that you have no active dental policy for the 2020 plan year.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare because they were performed after you dental plan had ended. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and two resin-based composites provided on March 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthoses (L1833, L2397) provided December 4, 2019.
You asked the Plan to pay for the knee orthoses. You say that the items were medically necessary. The Plan denied your request. The Plan says insufficient medical documentation was provided to support the items billed.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. Records provided were limited to the order and the delivery ticket. No office notes or clinical documentation to show a relationship between the physician and patient were provided. The provided records do not show clinical details such as duration of the patient's condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for knee orthoses (L1833, L2397) provided December 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post-stabilization inpatient care provided December 27 to December 31, 2019.
You asked the Plan to pay for post-stabilization inpatient care. You say that the services were medically necessary. The Plan denied your request. The Plan says the enrollee was stable for transport to a plan facility.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.
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 post-stabilization inpatient care. Our reviewer says that the services were not medically necessary. Our physician reviewer found the review indicates that the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan facility after the emergency room evaluation was performed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of post-stabilization inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for post-stabilization inpatient care provided December 27 to December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on May 11, 2018.
You asked the Plan to waive the copayment for a CT scan. You say that you already paid your copayments and disagree with the additional charges. 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 $50 copayment for each radiological diagnostic service. You have been asked to pay a $50 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and 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 copayment for a CT scan provided on May 11, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency care and the inpatient
hospital care provided March 20, 2020 to March 24, 2020.
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 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 $90
copayment for emergency care and a $210 copayment per day, for days 1-6 per inpatient hospital admission.
You have been asked to pay a $930 copayment ($90 and $210 x 4 days= $840) for emergency care and
inpatient hospital care provided. 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 care and the
inpatient hospital care provided March 20, 2020 to March 24, 2020.