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

We decided that the Plan does not have to pre-approve6 outpatient office visits to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe office visits. You say that you were already being treated by this provider. You had breast muscle removal and you are ina lot of pain and you want to go back to the surgeon that did the procedure.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 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 the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve6 outpatient office visits 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 waive the coinsurance for an annual wellness exam and diagnostic
services provided by an out-of-network provider on August 20, 2020.
You asked the Plan to waive the coinsurance for an annual wellness exam and diagnostic services. You say that
this should have been a $0 copayment. The Plan denied your request. The Plan says the correct coinsurance has
been applied.
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 50%
coinsurance for outpatient diagnostic tests/out-of-network and physician/practitioner services/out-of-network.
You have been asked to pay a 50% coinsurance of the allowed amount for an annual wellness exam and
diagnostic services. The total allowed amount is $256.83. The total amount you are being asked to pay is
$128.41 ($256.83 x 50% = $128.41). The physician that provided these services is out-of-network; therefore,
the correct coinsurance has been applied. An annual wellness exam and diagnostic services falls within the
outpatient diagnostic tests/out-of-network and physician/practitioner services/out-of-network 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 coinsurance for an annual wellness exam and diagnostic services provide
by an out-of-network provider on August 20, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvephysical therapy services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvephysical therapy. You say that you need additional therapyThe Plan denied yourrequest. 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 the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvephysical therapy services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay foropen treatment of femoral fracture, proximal end, neck, internal fixation, or prosthetic replacement (27236) provided May 13, 2020. You asked the Plan to pay forthe treatment of femoral fracture. You say that please see attached medical records as requested with W9.The Plan denied your request. The Plan says provider cannot directly bill service. Original Medicare does not allow "ALL" professionals to directly submit charges for the services that they provide.The Plan must follow Medicare rules. Medicare rules say that this PPO plan will generally cover your medical care as long as the care you receive is considered medically necessary and you receive your care from a provider who is eligible to provide services under Original Medicare. As a member of the PPO plan you can receive your care from either a network provider or an out-of-network provider. 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the treatment of femoral fracture have not been met.Therefore, we decided that the Plan does not have to pay foropen treatment of femoral fracture, proximal end, neck, internal fixation,or prosthetic replacement (27236) provided May 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Oxycodone-Acetaminophen 5-325 mg tablet, Acetaminophen 325 mg tablet, and Diphenhydramine 25 mg capsule received.

You asked the Plan to pay for Oxycodone-Acetaminophen, Acetaminophen, and Diphenhydramine. You say that these drugs were medically necessary due to an emergency blood transfusion before chemotherapy.The Plan denied your request. The Plan says rules for payment have not been met.

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 pay fo rOxycodone-Acetaminophen 5-325 mg tablet, Acetaminophen 325 mg tablet, and Diphenhydramine 25 mg capsule received.

Benefits for Oxycodone-Acetaminophen, Acetaminophen, and Diphenhydramine may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve stereotactic body radiation therapy (SBRT).
You asked the Plan to pre-approve SBRT. You say that the services are necessary. The Plan denied your
request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically 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 SBRT. Our reviewer says that the
requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found based on the location of the site to be treated (axilla), evidence of growth on serial imaging, and
the absence of widespread disease, SBRT would be an accepted standard of care. A caveat would be that if
there is an intent to treat the chest wall with radiation for oligometastases, it would be most appropriate to do so
now (and not request separate authorization to treat that site in the near future).
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SBRT have been met. Therefore, we decided that the Plan has to pre-approve
stereotactic body radiation therapy (SBRT).
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional occupational therapy visit for the enrollee.

You asked the Plan to pre-approve the additional visit. You say that this is medically necessary.The Plan denied your request. The Plan says a home program is now reasonable.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 additional visit. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had extensive therapy already for this condition, and it does not appear that the enrollee's functional deficits require the unique skills of a professional therapist to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The  specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition, or to prevent or slow further deterioration.

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 additional visit have not been met.Therefore, we decided that the Plan does not have to pre-approve an additional occupational therapy visit for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Planhasto pre-approveCT scan of the abdomen and pelvis for the enrollee.You asked the Planto pre-approvethe scan. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthe doctor should state why other tests cannot help.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the presence of cervical lymphadenopathy as well as weight loss and night sweats are factors which are very worrisome for a systemic process, especially lymphoma. As such evaluation of the chest, abdomen and pelvis with CT would be the procedure of choice and should be approved.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 scan have been met.Therefore, we decided that the Planhas to pre-approveCT scan of the abdomen and pelvis for the enrollee.If the Plandoes 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/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha for the enrollee.
You asked the Plan to pre-approve Repatha. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under 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 Repatha for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora CT scan of the abdomen and pelvis (74176) performed on July 27, 2020.You asked the Plan to waive the copayment fora CT scan of the abdomen and pelvis. You say that this is an annual exam that has never cost you so much before.The Plan denied your request. The Plan says the correct copayment was applied.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 $180 copayment for advanced imaging services. You have been asked to pay a $180 copayment for a CT scan of the abdomen and pelvis. ACT scan of the abdomen and pelvis 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 foraCT scan of the abdomen and pelvis (74176) performed on July 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve chiropractic services. You say that this provider can treat your specific needs and he is closer to your house. 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 the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve chiropractic services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe CT Scan of the thorax (71250).You asked the Plan to pre-approvethe CT Scan. You say that you would like reconsideration because the member meets coverage criteria for the service at issue.The Plan denied your request. The Plansays this service is not covered for screening purposes.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal, the CT Scan, is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Of note, the Plan has stated that coverage for CPT code G0297, a low does CT Scan for lung cancer screening, can be approved with a new request.Therefore, we decided that the Plan does not have to pre-approvethe CT Scan of the thorax (71250).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waivethe copayment for physician services provided on September 29, 2020.You asked the Plan to waivethis copayment. You say that you do not believe this copayment is correct.ThePlan denied your request. The Plan says this copayment was charged based on the service provided and the Plan contract agreement.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 $50 copayment for specialist services. 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 waivethe copayment forphysician services provided on September 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit 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 is not being used for a medically accepted indication.
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 based on the medical records provided there is no documentation that the Retacrit is medically reasonable and necessary for the enrollee. Retacrit is not indicated for use in enrollee with cancer receiving myelosuppressive chemotherapy when the anticipated outcome is cure. There is no indication from the provided records that the treatment for this enrollee is not intended to cure. 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 Retacrit for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Levofloxacin tab provided on March 2, 2020.You asked the Plan to pay forthe Levofloxacin tab. You say that this drug was administered by a nurse, and you were instructed to take it. You also say that you do not believe this drug was self-administered because you do not recall a pill being given.The Plan denied your request. The Plan says the Levofloxacin tab is a self-administered drug. The Plan also says that Part B generally does not pay for self-administered drugs used in the hospital outpatient setting.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 pay forthe Levofloxacin tab provided on March 2, 2020.Benefits for the Levofloxacin tabmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an ear to ear radiographic image (X-Ray) of teeth (D0330), doctor consultation on diagnosis (D9310), surgery to remove teeth (D7210), bone graft for dental ridge (D7953) and tissue regrowth procedure (D4266) provided on June 16, 2020.
You asked the Plan to pay for an X-ray of teeth, consultation, surgery, bone graft and tissue regrowth procedure. You say that the services should be covered. The Plan denied your request. The Plan says you entered a private contract with a provider who has opted out of Medicare.
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. The provider must be eligible under Medicare in order to be covered. 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. Specifically, you went to a provider who has opted out of Medicare, and therefore, the services are not covered. Therefore, we decided that the Plan does not have to pay for an ear to ear radiographic image (X-Ray) of teeth (D0330), doctor consultation on diagnosis (D9310), surgery to remove teeth (D7210), bone graft for dental ridge (D7953) and tissue regrowth procedure (D4266) provided on June 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial.
You asked the Plan to pre-approve the SCS trial. You say that the enrollee would benefit from this treatment.
The Plan denied your request. The Plan says the criteria for the SCS trial are not met.
The Plan follows Medicare rules. Medicare rules say that SCS trials are considered reasonable and necessary
when the above 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 pre-approve the SCS trial. Our reviewer says that
the requested SCS trial is not considered reasonable and necessary. Our physician reviewer found the enrollee
has chronic low back pain with lumbar radiculopathy. She has tried therapy, rest, ice, heat, non-steroid antiinflammatory
drugs, and muscle relaxants. She had an Epidural steroid injection which did help. Her current
medications include BELBUCA, Percocet, Topiramate and gabapentin. There is no imaging of her lumbar
spine submitted for review and she has not had lumbar spine surgery. The patient does not have an evidencebased
indication for aa SCS trial. She does not meet the NCD criteria. 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 SCS trial have not been met. Therefore, we decided that the Plan does not
have to pre-approve a spinal cord stimulator (SCS) trial.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay foranesthesia service provided on July 9, 2020.You asked the Plan to pay foranesthesia. You say that the enrollee's hospice status was revoked before admission.The Plan denied your request. The Plan says the denial of payment for this service is correct, because Original Medicare is responsible for coverage of benefits until the last day of the month in which hospice is revoked.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended MedicareHospice benefits on July 8, 2020. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay foranesthesia service provided on July 9, 2020.