Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the servicesarenecessary.The Plan denied your request. The Plan says based on the documentationprovided, 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 above.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 enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does have a documented need for skilled therapy, including physical and occupational therapy, but there is no documented need for an intensive, complex interdisciplinary rehabilitation course. 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea dental crown for tooth #10.You asked the Plan to pre-approvethe dental crown. You say that you are unable to bite down, and are experiencing pain.The Plan denied your request. The Plan says you have had this service less than 60 months ago.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. We looked at the file, and Medicare rules. The documentation showsthat you previously received a crown for tooth #10 on January 31, 2017. Your plan only covers crowns once per tooth every 5 years. Based on this information, we decided that the Plan's rules for coverage of the dental crown have not been met. Therefore, we decided that the Plan does not have to pre-approvea dental crown for tooth #10.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea semi-electric hospital bed for the enrollee.You asked the Plan to pre-approvea semi-electric hospital bed. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that the documentation does not indicate that the member requires frequent and immediate need for a change in body position.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:1. Has a medical condition which requires positioning ofthe body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requires frequent changes in body position and/or has an immediate need for a change in body position.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 semi-electric hospital bed. Our reviewer says that a semi-electric hospital bed is not medically reasonable and necessary for the enrollee in this case. The patient's condition does not require positioning of the body in ways not feasible in an ordinary bed. The patient does not require frequent or immediate changes in body position or need special attachments that cannot be fixed on an ordinary bed. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a semi-electric hospital bed.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 semi-electric hospital bed have not been met.Therefore, we decided that the Plan does not have to pre-approvea semi-electric hospital bed for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from April 15, 2020
through April 18, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your
cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim
was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received inpatient hospital care from April 15, 2020 through April 18, 2020.
At the time of services rendered you had not met your $750 deductible; therefore, you have been asked to pay
$371.98 for the services to apply to your deductible. Since you met your deductible you are asked to pay a
$300 copayment for the inpatient hospital care. 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 inpatient hospital care from April 15, 2020
through April 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and x-rays provided on February 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an office visit and x-rays. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these 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 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 has network providers available who can provide 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 an office visit and x-rays provided on February 6, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says for Part B coverage, this drug is subject to step therapy.
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 the drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has trialed
and failed Retacrit. This drug would not likely be less effective and/or likely to have adverse effects for the
enrollee. There was no submitted rationale for using the requested medication instead of the plan's preferred
drug Retacrit. Aranesp is 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 the drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Aranesp for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network provider.
You asked the Plan to pre-approve the services. You say that the services cannot be provided in-network. The Plan denied your request. The Plan says the services are available in-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 medical services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on February 6, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that the enrollee has never had to pay a copayment for a pre-procedure interview. The Plan denied your request. The Plan says you have been charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $50 copayment for provider and professional services at an in-network specialist's office. The enrollee has been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the enrollee was seen at billed by a pain clinic which is considered a specialty.
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the specialist office visit provided on February 6, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the ultrasound (76770). You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says utilization of network providers is required when possible and available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 has network providers available who can provide 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 medical services provided on December 23, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271).
You asked the Plan to pre-approve the Keytruda. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says compendia does not support this drug/regimen for the member's condition.
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 Keytruda. Our reviewer says that indications for biliary tract tumors are not supported by major drug compendia or the medical literature for pembrolizumab. Our physician reviewer found The use of pembrolizumab is not reasonable or medically necessary for this member. 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 Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9271).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for outpatient surgical services (CPT 24076) provided to the enrollee on August 29, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says that Current Procedural Terminology (CPT) code 24076 GC (1 unit) remains not supported 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 24076 is "Excision, tumor, soft tissue of upper arm or elbow area, subfascial (eg, intramuscular)."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 services. Our reviewers says that the services at issue in this case supported by the medical records. Our physician reviewer found the submitted records contain conflicting reports, the submitted pathology report indicates that the tumor was excised from forearm whereas the operative report indicates that the tumor was excised from arm. Per the reviewed operative note the lipoma was excised form the left arm. The review has determined that CPT 24076, Under Excision Procedures on the Humerus (Upper Arm) and Elbow was supported in the medical records.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 services have been met.Therefore, we decided that the Plan has to pay for outpatient surgical services (CPT 24076) provided to the enrollee on August 29, 2019.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 29, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because the doctor read the results of a test and said he couldn't help you. 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 $35 copayment per visit to a specialist. You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls 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 specialist visit provided on January 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 3, 2019.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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on December 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental exam (D0150) with an out-of-network dentist.
You asked the Plan to pre-approve the dental exam. You say that the services are medically necessary and should be covered. The Plan denied your request. The Plan says the dental benefit does not include coverage for services provided out-of-network.
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. Only dental services received from participating providers are eligible for coverage. Therefore, we decided that the Plan does not have to pre-approve a dental exam (D0150) with an out-of-network dentist.
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 above.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 enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does have a documented need for skilled therapy, including physical and occupational therapy, but there is no documented need for an intensive, complex interdisciplinary rehabilitation course. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for PT/INR testing (G0249) provided on January 17, 2020 through January 24, 2020.
You asked the Plan to pay for the PT/INR testing. You say that you would like reconsideration because CPT code G0429 has no frequency limitation. The Plan denied your request. The Plan says this code has a frequency limitation of no more than one unit per 25 days which has been exceeded.
The Plan must follow Medicare rules. Medicare rules say that providers must bill with the correct code to describe the services rendered. The rules also say that testing with the home PT/INR system should not be done more than once per week. In this case, the definition of the code G0249 is Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include 4 tests. As this code encompasses four tests, billing for four tests weekly exceeds what is covered by Medicare. Evidence was submitted showing that payment for this code was made on January 10, 2020 which would include payment for four weekly tests. Payment of this code weekly would indicate testing four times per week, which is not covered by Medicare guidelines. Therefore, we decided that the Plan does not have to pay for PT/INR testing (G0249) provided on January 17, 2020 through January 24, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.You asked the Planto pre-approveSNF services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee could get the care needed at home.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar epidural injections.
You asked the Plan to pre-approve lumbar epidural injections. You say that these injections will help reduce
the enrollee's pain. The Plan denied your request. The Plan says the denial of authorization for these injections
is correct, because the Plan already approved 2 levels and 2 additional levels beyond this would not be covered
by Medicare in a single setting.
The Plan must follow Medicare rules. Medicare rules say that no more than 2 transforaminal injections may be
performed at a single setting (such as single level bilaterally or 2 levels unilaterally).
We looked at the file and Medicare rules. The Plan has already approved 2 levels unilaterally, therefore
additional injections would not be covered in the same setting. Based on this information, we decided that
Medicare rules for coverage of lumbar epidural injections have not been met. Therefore, we decided that the
Plan does not have to pre-approve lumbar epidural injections.