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

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.
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
was admitted for acute on chronic respiratory failure, pneumonia, pleural effusion, lung mass and subdural
hematoma. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary
care can be provided in a different level of care. 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ramucirumab, Paclitaxel, Carboplatin 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 this combination is not supported for metastatic non-small cell lung cancer.
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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found Carboplatin, Pacltiaxel, and Ramucirumab are not considered a standard of care for the treatment of non-small cell lung cancer. There is no off-label indications or support in the medical literature. The service 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Ramucirumab, Paclitaxel, Carboplatin for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure and comprehensive oral evaluation provided on November 11, 2020.
You asked the Plan to pay for the preventive procedure and comprehensive oral evaluation. You say that you only wanted a cleaning and bitewing x-rays. The Plan denied your request. The Plan says the preventive procedure is not a covered service. The Plan also says that your benefits for the comprehensive oral evaluation have been satisfied and the frequency limitation has been exceeded.
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 unspecified preventive procedure is not among those covered under this benefit. The contract says that comprehensive oral evaluation is limited to one procedure every three years. The record shows that you received a comprehensive oral evaluation on February 5, 2020 and your comprehensive oral evaluation benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the preventive procedure and comprehensive oral evaluation provided on November 11, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for Injection, epoetin alfa-epbx provided on November 21, 2019.
You asked the Plan to pay for Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000 units (Q5106). You say that the Plan should pay this claim. The Plan denied your request. The Plan says that the hemoglobin level was not documented.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not forwarded the clinical case notes and records reviewed in making their decision. Therefore, we decided that the Plan has to pay for Injection, epoetin alfa-epbx provided on November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a Physician's
Assistant (PA) at your neurologist's office.

You asked the Plan to waive the copayment for the office visit. You say that you shouldn't have to pay this
copayment because you didn't see a doctor. The Plan denied your request. The Plan says you were charged this
copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45
copayment for specialist visits (including Physician/Practitioner Services).

You have been asked to pay a $45 copayment for the office visit. The office visit falls within the specialist
visits (including Physician/Practitioner Services) benefit category because medical records from this visit
clearly show that you were evaluated in the neurologist's office. 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 office visit you had with a Physician's Assistant (PA) at your neurologist's office.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycodone, HCL, extended release 40 mg tablet
You asked the Plan to pre-approve Oxycodone, HCL. You say that the enrollee has been stable on this medication since January 17, 2016. You say that the enrollee takes medication for chronic back pain and post-herpetic polyneuropathy. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.
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 Oxycodone, HCL, extended release 40 mg tablet
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L2397, L1833).
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that these items were medically necessary for the enrollee. The Plan denied your request. The Plan says there is no evidence prescribing physician ever saw the member.
The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to the criteria listed 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 pay for the knee orthosis and suspension sleeve. Our reviewer says that the items were not medically necessary and reasonable. Our physician reviewer found Based on the available documentation, there was insufficient objective support made for the above diagnosis or for prescribing the brace without a physical examination or video appointment. Therefore, the patient does not meet LCD criteria for the knee orthosis and suspension sleeve. 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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L2397, L1833).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Oncotype DX genetic testing panel provided with a
reported date of service of July 30, 2020.
You asked the Plan to pay for the Oncotype DX testing as billed. You say that this was correctly billed with the
DOS on which the testing was performed. The Plan denied your request. The Plan says this sample was taken
during an inpatient hospital encounter. As such, the correct DOS would be July 27, 2020, the date the specimen
was removed from storage.
The Plan must follow Medicare rules. Medicare rules say that for stored specimens, the DOS reported for
testing that takes place more than 30 days after the collection must be the date the specimen was retrieved from
storage. For ADLTs, the date should be the date the testing was performed only when the specimen was
obtained from a hospital outpatient.
In this case, although this test qualifies as an ADLT, the specimen was taken in the inpatient setting. As such,
the rules allowing reporting of the date the testing was actually performed do not apply. This would be subject
to the rule for stored specimens and since the specimen was tested more than 30 days after collection, which
was on June 10, 2020, the date the specimen was taken from storage is the correct DOS. Therefore, we decided
that the Plan does not have to pay for the Oncotype DX genetic testing panel provided with a reported date of
service of July 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.

You asked the Plan to pay for the ambulance services. You say that you did not want to go to the hospital because of risks of COVID-19. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.

The ambulance company did not provide transport services. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the initial periapical x-ray, amalgam, resin-based composite, periodic oral exam, and prophylaxis. We decided that the Plan does not have to pay for the limited oral evaluation and the additional periapical x-ray.

You asked the Plan to pay for the initial periapical x-ray, amalgam, resin-based composite, periodic oral exam, and prophylaxis. You say that you were not told that the provider had opted out of Medicare. You say that the office staff was not helpful and rude. You say that this claim should be covered You also say that you feel that you were misled by the office staff. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan says that payment cannot be made to providers who have chosen to opt out of Medicare.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 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 decided that the Plan has to pay for the initial periapical x-ray, amalgam, resin-based composite, periodic oral exam, and prophylaxis.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. We find that the opt-out rule for providers only applies to Medicare-covered benefits as confirmed by CMS. Supplemental dental services are not covered by Medicare and therefore Medicare rules cannot be applied to these services. Therefore, we decided that the Plan has to pay for the initial periapical x-ray, amalgam, resin-based composite, periodic oral exam, and prophylaxis.

We also decided that the Plan does not have to pay for the limited oral evaluation and the additional periapical x-ray.

Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation is not among those covered under this benefit. Additionally, the frequency limit of 1 periapical x-ray has been exceeded. The record shows that with the payment of the initial periapical x-ray provided on this date of service, the frequency limit will have been reached. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation and the additional periapical x-ray.

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 copayments for office visits provided from January 22, 2020, to June 24, 2020.
You asked the Plan to waive the copayments for office visits. You say that you are being charged facility charges and disagree with the 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 $5 copayment for each primary care provider visit. You received office visits provided from January 22, 2020, to June 24, 2020, for a total of 3 visits. Therefore, you are responsible to pay a $5 copayment per each visit. The total amount you owe is: $15. You have been asked to pay the total copayment amount of $15 for office visits. Office 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 copayments for office visits provided from January 22, 2020, to June 24, 2020.
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 you need SNF care to get back to everyday activities. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.
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 you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 was admitted for surgical treatment of femur fracture, non-surgical management of a humerus fracture and non-surgical management of traumatic brain injury, all after a fall in her home. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for initial hospital care.

You asked the Plan to waive the deductible for initial hospital care. You say that you disagree with the $853.51
charges because they are too high. 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. Your
contract with the Plan says that there is a $1,000 deductible for inpatient hospital care.

You received initial hospital care. The record shows that you had paid $0 toward the $1,000 deductible 
prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of $853.51.

The item or service you asked the Plan to waive the deductible for falls within the benefit category inpatient
hospital care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000
deductible for inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the
time initial hospital care. Therefore, we decided that the Plan does not have to waive the deductible for initial 
hospital care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Myriad myRisk panel rendered on January 14, 2020.
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 the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of personal history of in-situ neoplasm of the breast. No.
The case file does not contain any clinical medical records for this enrollee. Consequently, it cannot be determined that the enrollee met all of the criteria for coverage or that the testing was 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 pay for the Myriad myRisk panel rendered on January 14, 2020.