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

We decided that the Plan does not have to pay for post-stabilization inpatient care provided August 18 to August 20, 2019.
You asked the Plan to pay for the inpatient services. You say that the services were medically necessary. The Plan denied your request. The Plan says the enrollee was stable for transfer 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 the inpatient services. Our reviewer says that rules for coverage were not met. Our physician reviewer found there was no documentation provided necessitating post-stabilization care services at the non-plan facility. The post-stabilization care services were not medically necessary and 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 inpatient services have not been met. Therefore, we decided that the Plan does not have to pay for post-stabilization inpatient care provided August 18 to August 20, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveProlia.You asked the Plan to pre-approveProlia. You say that the requested Prolia is medically necessary.The Plan denied your request. The Plan says that the requested Prolia is 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 Prolia. Our reviewer says that the requested Prolia is medically necessary. Our physician reviewer found the enrollee has documented osteoporosis and has been taking Prolia with documented success. He is taking supplemental Calcium and Vitamin D. The Plan is denying the medication because he does not have a Calcium blood level documented on the chart. The enrollee is already on this medication and he is taking therecommended supplementation. The enrollee does NOT complain of any of the signs of hypocalcemia. The package insert does NOT state that routine monitoring of blood calcium levels is required. The medication is medically reasonable and necessary in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have been met.Therefore, we decided that the Plan has to pre-approveProlia.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forpost-stabilization inpatient care provided August 12 to August 16, 2019.You asked the Plan to pay forthe inpatient services. You say that the services were medically necessary.The Plan denied your request. The Plan says the enrollee was stable for transfer 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 the inpatient services. Our reviewer says that coverage criteria was not met. Our physician reviewer found the enrollee could have been safely transported to a plan facility for continuing care without an expected decline in her condition.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 inpatient services have not been met.Therefore, we decided that the Plan does not have to pay forpost-stabilization inpatient care provided August 12 to August 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care rendered on November 25, 2018.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 claim was not filed timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for these services was not filed until January 1, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe initial hospital care rendered on November 25, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveInterferon Alfa 2B.You asked the Plan to pre-approvethe Interferon Alfa 2B. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the medication is self-administered, and therefore is not covered under Medicare Part B.The Plan must followMedicare 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-approveInterferon Alfa 2B.Benefits for the Interferon Alfa 2Bmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that you feel that the CGM should be allowed because the enrollee would be able to test more easily up to four times per day which would be better for his condition. The Plan denied your request. The Plan says the criteria for this device are not met.
The Plan must follow Medicare rules. Medicare rules say that CGMs covered when the above listed criteria are met. The documentation does not show that the enrollee tested at least four times per day or requires three or more insulin injections. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on December 10,
2019.
You asked the Plan to waive the copayment for the office visit. You say that you scheduled an annual wellness
visit but are being billed for an office visit. The Plan denied your request. The Plan says the copayment applied
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 $10
copayment per primary care physician (PCP) visit.
You have been asked to pay a $10 copayment for the office visit. The office visit falls within the
"Physician/Practitioner services, including doctor's office visits" benefit category. The records show that a
regular office visit was performed. 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
provided on December 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient hospital stay and surgery provided on November 18, 2019 to November 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an inpatient hospital stay and surgery. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that these services were considered elective and not an emergent/urgent service.
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 inpatient hospital stay and surgery provided on November 18, 2019 to November 20, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea LINX procedure.You asked the Plan to pre-approvethese services. You say that the services are medically necessary.The Plan denied your request. The Plan says the 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found LINX is a standard, FDA-approved treatment for gastroesophageal reflux disease (GERD) that is refractory to medical management. The enrollee has an abnormal motility study, suggesting esophageal outflow obstruction, which would be considered a clinical exclusion to the LINX procedure. The services are 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 not been met.Therefore, we decided that the Plan does not have to pre-approvea LINX procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on November 7, 2019.You asked the Plan to pay forthe dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says the Medicare rules have not been met.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. We reviewed your records and they show you had infected dental roots requiring surgical excision. The record sent by your provider indicates that tooth #20 required removal and placement of a bone graft.Therefore, we decided that the Plan does not have to pay forthe dental services provided on November 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary.The Plan denied your request. The Plan says it is unclear if the enrollee can progress off the ventilator, with the progressive my asthenia gravis.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 the enrollee is currently undergoing treatment at an ACH for respiratory failure attributed to probable Guillain-Barrsyndrome in the setting of morbid obesity. The enrollee required intubation/ventilation and subsequently received a tracheotomy. There are some noted problems with the size/position of the trach. It is unclear when the enrollee will be appropriate for ventilator weaning. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-termcare needs.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 Plandoes not haveto pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 25, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the medical services provided to the enrollee by an out-of-network provider on November 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided to the enrollee on December 23, 2019.
You asked the Plan to pay for the provided orthotics. The Plan denied your request. The Plan says the documentation did not indicate the provider discussed a need for the items.
The Plan follows Medicare rules. Medicare rules say that knee orthoses are only covered under certain medical indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the provided orthotics. Our physician reviewer found that the documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee. There is no documentation of recent injury to, or recent surgical procedure on either of the enrollee's knees. There is no objective documentation of joint laxity. The suspension sleeve is not separately payable when the base item is not covered. 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 provided orthotics have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided to the enrollee on December 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ENTYVIO injection, 300 mg.
You asked the Plan to pre-approve the ENTYVIO injection. You say that the ENTYVIO is medically necessary. The Plan denied your request. The Plan says ENTYVIO is subject to step therapy. The Plan says there is no evidence that the enrollee has had prior therapy, contraindication, or intolerance with the approved drugs, Remicade or INFLECTRA; and STELARA. The Plan also says that the requested ENTYVIO is not medically necessary.
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 ENTYVIO. Our reviewer says that ENTYVIO is not medically necessary. Our physician reviewer found the documentation does not support that Remicade or INFLECTRA; and STELARA would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Therefore, the reviewer found that the request for ENTYVIO 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 ENTYVIO have not been met. Therefore, we decided that the Plan does not have to pre-approve the ENTYVIO injection, 300 mg.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from October 4, 2019 to October 29, 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 the claims were not billed correctly.
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home health services under a plan of treatment. We looked at the file and Medicare rules. The claims were not billed with a valid TOB code. 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 home health services rendered from October 4, 2019 to October 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forpanoramic radiographic image (D0330) provided on December 20, 2019.You asked the Plan to pay forthe dental services. You say that you were not aware that the x-ray is not covered.The Plan denied your request. The Plan says the service is not a covered benefit under the plan.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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered.Therefore, we decided that the Plan does not have to pay forpanoramic radiographic image (D0330) provided on December 20, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forwide-area transepithelial sampling (WATS 3D) testing provided on August 16, 2019.You asked the Plan to pay forWATS 3Dtesting. You say that this testing was ordered after the treating physician made a determination of medical necessity.The Plan denied your request. The Plan says that the denial of payment for these services is correct.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 rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered.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 did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted did not include prior notice that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care, which would justify coverage of this testing. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay forwide-area transepithelial sampling (WATS 3D) testing provided on August 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive periodontal evaluation - new or established patient (D0180) provided on December 5, 2019.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you exhausted your benefit frequency limit.
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. Your claims history supports that the maximum allowed for oral exam limitation has been met. Your EOC clearly states, dental exams (D0120-D0180) are covered for two (2) exams per calendar year. You used your oral exam benefits on August 28, 2019 and September 24, 2019. Therefore, you would not be eligible for an exam (D0120-D0180) until January 1, 2020. Therefore, we decided that the Plan does not have to pay for comprehensive periodontal evaluation - new or established patient (D0180) provided on December 5, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forscreening mammography provided on December 3, 2019.You asked the Plan to pay forscreening mammography. You say that you did not know the previous screening mammogram would be submitted to the Plan, and if you had known you would not have had it.The Plan denied your request. The Plan says the denial of payment for this service is correct, because screening mammography is only covered once every 12 months by Medicare and the Plan.The Plan must follow Medicare rules. Medicare rules say that screening mammography is only covered after at least 11 monthshave passed following the month in which the last screening mammography was performed (or once every 12 months). We looked at the file and Medicare rules. You received screening mammography less than 12 full months prior to this date of service. Based on this information, we decided that Medicare rules for coverage of screening mammography have not been met.Therefore, we decided that the Plan does not have to pay forscreening mammography provided on December 3, 2019.