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

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a SNF. You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not have complex wound care or other ongoing SNF level SN need. The enrollee's functional level does not require skilled therapy serviceswith the specialized skill, knowledge and judgment of a qualified therapist to safelyand effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a SNF. As a practical matter, this enrollee 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 admission to a SNF have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvespecial supplemental benefits.You asked the Plan to pre-approvethese services. You say that you are interested in receiving the supplemental benefits.The Plan denied your request. The Plan says you do not meet the criteria for coverage.The Plan must follow Medicare rules. The rules say that only services not covered by Original Medicare may be covered under supplemental benefits. The Plan contract says that supplemental benefits are covered for enrollees with specific medicallycomplex chronic conditions.We looked at the file and Medicare rules. The file shows that you do not have a medical condition for which the Plan covers supplemental benefits. Based on this information, we decided that Plan's rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvespecial supplemental benefits.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foremergency care provided on September 11, 2020.You asked the Plan to waive the copayment foremergency care. You say that you had to return to the emergency room for additional stitches and feel that you should not owe an additional copayment.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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 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 waive the copayment foremergency care provided on September 11, 2020.We note your complaint that you had to return to the emergency room for additional stitches. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe deep sedation/general anesthesia services (D9222, D9223).You asked the Plan to pre-approvethe deep sedation/general anesthesia services. You say that the services are medically necessary for your condition.The Plan denied your request. The Plan says these dental services are not covered under your supplemental coverage.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.Therefore, we decided that the Plan does not have to pre-approvethe deep sedation/general anesthesia services (D9222, D9223).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hand x-ray rendered on May 31, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 73130 was not billed correctly.The Plan must follow Medicare rules. The rules say that anatomical modifiers are required for procedures performed on different anatomical sites.We looked at the file and Medicare rules. The file shows that procedure code 73130 was not billed with the required anatomical modifier. 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 forthe hand x-ray rendered on May 31, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDoxorubicin HclLiposome, Palonosetron Hcl and Dexamethasone for the enrollee.You asked the Plan to pre-approveDoxorubicin Hcl Liposome, Palonosetron Hcl and Dexamethasone. You say that these drugs are medically necessary.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 Doxorubicin Hcl Liposome, Palonosetron Hcl and Dexamethasone. Our reviewer says that Doxorubicin Hcl Liposome, Palonosetron Hcl and Dexamethasone are not medically reasonable and necessary for the enrollee in this case. These drugs are beingrequested for untreated metastatic triple negative breast cancer. The documentation indicates the enrollee  has not yet been treated. Therefore, she has not been treated with Doxorubicin or Epirubicin. Doxorubicin or Epirubicin are not likely to be less effective or more likely to have adverse effects than Liposomal Doxorubicin. Per the NCCN Guidelines both Doxorubicin and Liposomal Doxorubicin are preferred regimens.  Epirubicin is listed among other recommended regimens. The use of Palonosetron would be not be considered medically reasonable and necessary for use with Liposomal Doxorubicin. Per the NCCN Liposomal Doxorubicin has low emetic potential. In the same guideline, Dexamethasone is considered medically reasonable and necessary but Palonosetron is not among the recommended drugs. The reasonableness and safety of Dexamethasone and Palonosetron are clinically linked to the determination of the primary chemotherapy drug and cannot be more clearly reviewed separately. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Doxorubicin Hcl Liposome, Palonosetron Hcl and Dexamethasone.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Doxorubicin Hcl Liposome, Palonosetron Hcl and Dexamethasone have not been met.Therefore, we decided that the Plan does not have to pre-approveDoxorubicin Hcl Liposome, Palonosetron Hcl and Dexamethasone for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea wheelchair ramp.You asked the Plan to pre-approvea wheelchair ramp. You say that you cannot use the wheelchair effectively without a ramp to get in the house.The Plan denied your request. The Plan says Medicare does not cover home modifications.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvea wheelchair ramp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea continuous glucose monitor.You asked the Plan to providea continuous glucose monitor. You say that you have trouble with a regularstick reader because of your medical conditions.The Plan denied your request. The Plan says criteria is not met for a continuous glucose monitor.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based onthe blood glucose testing results.We looked at the file and Medicare rules. The documentation indicates that you are not insulin treated. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to providea continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea transport chair.You asked the Plan to pre-approvethese services. You say that it is too difficult for the enrollee to walk while out shopping.The Plan denied your request. The Plan says the item is not covered for use outside of the home.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approvea transport chair
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveendocrinology specialist services to be provided by an out of network (OON) provider.You asked the Plan to pre-approveendocrinology specialist services. You say that you would like approval for these services to be provided out-of-network.The Plan denied your request. The Plan says there are in-network providers available for 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require thePlan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approveendocrinology specialist services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe outpatient office visit (99214) to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe outpatient office visit. You say that this has been your ophthalmologist since 2004. You have reviewed all of the Plan's ophthalmologists and can find none with the experience of this provider, especially with narrow angle.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.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 providerwith the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe outpatient office visit (99214) to be provided by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a age-related osteoporosis without current pathological fracture. She has not tried and failed the Plan's required drug of zoledronic acid. The records do not support that the required drug would be contraindicated or less effective; therefore, Prolia 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 Prolia.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided from June 22, 2020, to July 7, 2020.
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you were told that you owed a $0 copayment. 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 $20 copayment for outpatient rehabilitation services provided in a specialist's office or a comprehensive outpatient rehab facility and a $40 copayment when provided in an outpatient hospital setting. You received outpatient rehabilitation services from June 22, 2020, to July 7, 2020 for a total of 5 visits. Therefore, you are responsible to pay a $20 copayment per each visit. The total amount you owe is: $20 (copayment) x 5 (outpatient rehabilitation visits) = $100. You have been asked to pay the total copayment amount of $100 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation services 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 outpatient rehabilitation services provided from June 22, 2020, to July 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Contiuous Glucose Monitor (CGM).You asked the Plan to pre-approvethe CGM. You say that the CGM is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that a CGM is covered when the beneficiary is insulin-treated with multiple (three or more) daily injections of insulin. We looked at the file and Medicare rules. The records provided do not show that the enrollee is treated with three or more injections of insulin daily. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met.Therefore, we decided that the Plan does not have to pre-approvea Contiuous Glucose Monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 1, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because the member has a condition which is indicated for this testing. The Plan denied your request. The Plan says no authorization was obtained prior to rendering 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 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 July 1, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNFservices.You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for SNF 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 thePlan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are notmedicallynecessary. Our physician reviewer found that from a nursing perspective, the enrollee received enteral nutrition and medications. The enrollee had stable vital signs. She was treated for pain with effect. Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT). The enrollee was at a dependent level for functional mobility and with activities of daily living. There areidentifiable skilled nursing service needs.There are no identifiable skilled therapy service needs.The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for 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 SNFservices.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on June
30, 2020.
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you disagree with the
charges because you were never charged for a diagnostic mammogram in the past. 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 $100
copayment for diagnostic procedures and tests provided in an outpatient hospital facility.
The medical records show that you received a diagnostic mammogram on June 30, 2020. Therefore, you are
responsible to pay $50, which is less than the $100 copayment.
You have been asked to pay $50 for a diagnostic mammogram. A diagnostic mammogram falls within the
outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for a diagnostic mammogram provided on June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveparavertebral lumbosacral facet joint blocks.You asked the Plan to pre-approvethe paravertebral lumbosacral facet joint blocks. You say that the injection services are medically necessary.The Plan denied your request. The Plan says the records provided do not show an examination of the back. The Plan says that the criteria for coverage of the requestedinjection services have not been met.The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered for certain medical indications.We asked our physician reviewer to carefully review the case file and apply the relevantMedicare rules to determine if the Plan was correct in denying the request to pre-approve the paravertebral lumbosacral facet joint blocks. Our reviewer says that the requested injections are not medically necessary. Our physician reviewer found the enrollee has low back pain associated with radiculopathy.  The review has determined that the enrollee does not meet the criteria for the requested injections 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 paravertebral lumbosacral facet joint blocks have not been met.Therefore, we decided that the Plan does not have to pre-approveparavertebral lumbosacral facet joint blocks.