Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trintellix tablets.
You asked the Plan to pre-approve Trintellix. You say that the enrollee is on samples of this medication and doing well. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's Part D prescription drug plan.
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 Trintellix tablets.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pembrolizumab for the enrollee.
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 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 not medically necessary. Our physician reviewer found the enrollee has non-small cell lung cancer (NSCLC) that was treated with cisplatin and pemetrexed in 2017. Scans from February of 2020 show progression of disease. The records indicate a plan to treat with pembrolizumab with chemotherapy, perhaps pemetrexed. Pembrolizumab is FDA-approved as a single-agent treatment of metastatic NSCLC in patients with tumors with PD-L1 expression, as determined by an approved test, and with disease progression on or following platinum-containing chemotherapy; therefore, the pembrolizumab 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 pembrolizumab for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One injections for the enrollee.
You asked the Plan to pre-approve Gel-One. The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception.
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 Gel-One. Our reviewer says that Gel-One is not medically reasonable and necessary for the enrollee in this case. The enrollee has not tried and failed the required drugs Orthovisc and Monovisc. The documentation does not reveal evidence that the enrollee has extenuating factors that would reveal the plan's required drugs are less effective or would have adverse effects for the enrollee. There is no evidence that the enrollee has had prior treatment, contraindication or intolerance of Orthovisc or Monovisc. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Gel-One. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One injections for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lenses (V2781) miscellaneous vision services (V2799) on September 14, 2019.
You asked the Plan to pay for the vision services. You say that you are allowed up to the plan maximum amount for eyeglasses and frames or contact lenses and you have not had any claims for eyeglasses this year or in 2018 so this should not be denied. The Plan denied your request. The Plan says this claim was processed correctly
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay any amount over the $200 eyewear benefit allowance for Vision care. You have been asked to pay $200 for the vision services. The total billed amount was $400. The $200 maximum eyewear benefit was applied. The vision services fall within the Vision care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay for progressive lenses (V2781) miscellaneous vision services (V2799) on September 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the artery ultrasound provided on August
14, 2019.
You asked the Plan to waive the copayment for the artery ultrasound. You say that you were not informed that
the provider was out-of-network. 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 $75
copayment for each Medicare-covered radiological diagnostic service.
You have been asked to pay a $75 copayment for the artery ultrasound. The artery ultrasound 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 the artery ultrasound provided on August 14, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the SNF services are medically necessary. The Plan denied your request. The Plan says services can be provided at a lower level of care.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the patient does not require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis. As a practical matter this patient does not require the necessary services on an inpatient basis, in a skilled nursing facility 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on October 9, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you found this doctor on medicare.gov. The Plan denied your request. The Plan says no prior authorization was obtained for this service. The Plan says that there are in-network providers available for this 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 office visit provided on October 9, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve self-administered Morphine Sulfate tablets for the enrollee.
You asked the Plan to pre-approve this request. You say that this drug is medically necessary. The Plan denied your request. The Plan says self-administered drugs are 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 self-administered Morphine Sulfate tablets for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from February 11, 2019 through February 13, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found even if the enrollee had been hospitalized under observation status, conversion to inpatient status under the two midnight rule would have been warranted. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from February 11, 2019 through February 13, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
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 the services are 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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on February 29, 2020 with numbness and tingling in his hand and he developed extremity weakness. He was found to have multiple small acute infarcts in the right frontoparietal right occipital lobe. On March 2, 2020 his vital signs were stable and he was in no acute distress. He needs contact guard assist with ambulating 150 feet with a walker. He is modified independent for bed mobility. The complexity of his nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. He may benefit from further therapy but does not require an intensive therapy program 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis, bitewings, and periodic oral evaluation provided on October 15, 2019.
You asked the Plan to pay for the prophylaxis, bitewings, and periodic oral evaluation. You say that the provider's office staff member verified that you had coverage for your dental services. The Plan denied your request. The Plan says these services are not covered because they were performed after your plan had ended.
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. The record shows that your coverage termed on October 31, 2018. Therefore, we decided that the Plan does not have to pay for the prophylaxis, bitewings, and periodic oral evaluation provided on October 15, 2019.
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 the claim should be paid because you would have died if the responding Fire District had not treated your condition. You say that your blood sugar levels had dropped significantly which was a result of your doctor changing your insulin. After the responder's treatment you were offered transportation to the hospital, however you declined since your husband could take you there. You say that the Plan should pay the claim. 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 on July 20, 2019. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for testing services (80157, 80159, 8016280173, 80177, 80201,80307, and G0483) provided to the enrollee on September 4, 2019.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria were not met. The Plan states that the place of service ((POS) on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on September 4, 2019 and the laboratory report date of service was on September 5, 2019. Of note, the patient resides in Alabama and the billing laboratory is in Georgia; therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate place of service (POS) codes. In this case, the records provided do not support the POS codes submitted on the claim. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for testing services (80157, 80159, 8016280173, 80177, 80201,80307, and G0483) provided to the enrollee on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided on October 25, 2019.
You asked the Plan to waive the copayment for specialist services. You say that a doctor walked in and asked if you were fine. You say that no office visit occurred. The Plan denied your request. The Plan says the correct copayment has been applied to the service that was 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 $30 copayment for outpatient hospital services/specialist visit. You have been asked to pay a $30 copayment for specialist services. Evidence was provided to show that physician services were provided; therefore, the correct copayment has been applied. Specialist services fall within the outpatient hospital services/specialist visit 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 specialist services provided on October 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH 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. 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 services are not medically necessary. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for shortness of breath attributed to pneumonia, CHF and pulmonary fibrosis. The enrollee has received antibiotics, diuresis and supplemental oxygen. The enrollee is not intubated/ventilated. 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. 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 for the enrollee.
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 June 26, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you are retired and $30 is a lot of money. 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). Your contract with the Plan clearly says that you must pay a $30 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. You have been asked to pay a $30 copayment for the specialist office visit. The specialist office 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 the specialist office visit provided on June 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a home health visit provided on June 25, 2019 to July 31,
2019 by an out of network (OON) provider.
You asked the Plan to pay for a home health visit. You say that these services were medically necessary. The
Plan denied your request. The Plan says no prior authorization was obtained.
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 a home health visit provided on June 25, 2019 to
July 31, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to adjust the reimbursement for the ocular prosthesis provided on May 14, 2019.
You asked the Plan to adjust the reimbursement for the prosthetic eye. You say that the Plan should pay more for your prosthetic eye. The Plan denied your request. The Plan says you were reimbursed the Medicare allowed amount minus your coinsurance.
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 30% coinsurance for out-of-network providers for prosthetic devices and related supplies. You have been asked to pay 30% coinsurance for out-of-network providers for the prosthetic eye. The prosthetic eye falls within the prosthetic devices and related supplies benefit category. The Plan has reimbursed you according to the Medicare Fee Schedule and your contract coinsurance. This means that you have been paid the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to adjust the reimbursement for the ocular prosthesis provided on May 14, 2019.