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

We decided that the Plan does not have to pre-approve Gazyva, Lenalidomide, and Nivestym.
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 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 you have a diagnosis of diffuse large B-cell lymphoma. The combination of lenalidomide and Gazyva with nivestym support is not a standard treatment. It is not FDA approved and is not supported by major drug compendia. The requested drug regimen is therefore not reasonable or medically necessary or safe and effective. 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 Gazyva, Lenalidomide, and Nivestym.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection respiratory panel rendered on January 28, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There are no submitted records to support that the infectious agent detection was medically necessary for the enrollee. 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 infectious agent detection respiratory panel rendered on January 28, 2020.
Local Coverage Article (LCA) A57579 referenced by the Plan is not valid for Part B Medicare for the state of Pennsylvania where the testing was rendered and was not used in the MAXIMUS determination.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and additional intraoral periapical x-ray (D0230) provided on November 21, 2019.
You asked the Plan to pay for the intraoral periapical x-rays. You say that you showed your EOC to the receptionist at the provider's office, and stated you wanted to receive the services that were covered. You also say that you cannot afford to pay for the denied charges. The Plan denied your request. The Plan says these services are not covered by 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. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and additional intraoral periapical x-ray (D0230) provided on November 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wig.
You asked the Plan to pre-approve the wig. The Plan denied your request. The Plan says that Medicare
guidelines state that a wig is not a covered benefit.
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are
ordered by a physician. The Plan follows these same rules.
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As
such, it is non-covered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided on February 3, 2020.
You asked the Plan to pay for the resin-based composite. You say that you needed this service so you could eat normally. The Plan denied your request. The Plan says your $1,500 calendar year maximum was exhausted.
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 Plan offers a $1,500 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on February 3, 2020 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the resin-based composite provided on February 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre Continuous Glucose Monitor (CGM) (E1399).
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary due to visual impairment. The Plan denied your request. The Plan says coverage criteria is not met for a CGM. The plan can provide a One Touch glucose meter (non CGM) specifically for visually impaired individuals if requested.
The Plan must follow Medicare rules. Medicare rules say that CGM's are only covered for enrollees who are insulin-treated with multiple daily injections of insulin or an infusion pump. Enrollees must test their blood glucose 4 or more times daily to qualify. We looked at the file and Medicare rules. The record shows the enrollee does not use insulin injections. The record shows the enrollee does not test at least 4 times 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-approve a Freestyle Libre Continuous Glucose Monitor (CGM) (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that an inpatient rehabilitation facility admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an inpatient rehabilitation facility admission.

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that you are medically stable with no evidence of a need for supervision by a physical medicine and rehabilitation physician or a need for acute rehabilitation nursing care. You may benefit from further physical and occupational therapy but do not require an intensive therapy program. An IRF admission is not medically necessary based on your current functional status and medical stability.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve admission to an inpatient psychiatric hospital.You asked the Planto pre-approvethe admission. You say that you still remain psychotic and disorganized, requiring continued medication adjustments and monitoring with an acute inpatient setting.The Plandenied your request. The Plansaysthere were no new medical records from June 11, 2020 to June 14, 2020 for progress regarding the anti-psychotic medication.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules todetermine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that based upon a review of the records provided for this admission, you do not meet the criteria for coverage. You are not shown to be a danger to yourself or others. There are no auditory or visual hallucinations. Our physician reviewer found 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 admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to an inpatient psychiatric hospital.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetestosterone cypionate.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says self-administered drugs are not covered.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-approvetestosterone cypionate.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc (J7325).
You asked the Plan to pre-approve Synvisc. You say that the enrollee is in pain at this time. The Plan denied your request. The Plan says the provided documentation does not support that Synvisc is 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 Synvisc. Our reviewer says that the Synvisc (J7325) does not meet coverage criteria. Our physician reviewer found intra-articular injections with hyaluronic acid (Synvisc) are recommended as a possible option for severe osteoarthritis for enrollees who have not responded adequately to recommended conservative treatments (exercise, NSAIDs, and/or Acetaminophen) to potentially delay total knee replacement. Our reviewer found that there is no documented radiologic evidence of osteoarthritis of the knee and no documentation of recent trial of conservative treatment including physical therapy and/or pharmacotherapy for at least 6 weeks. Our physician reviewer also found that the review has determined that the documentation does not support that the Synvisc (J7325) is medically reasonable, necessary, safe and effective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc (J7325).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingivectomy or gingivoplasty to allow access for restorative procedure (D4212) of tooth #'s 10 and 11.
You asked the Plan to pre-approve gingivectomies or gingivoplasties. You say that you are unable to eat properly or on the left side of your mouth. You also say that you really need this work done. The Plan denied your request. The Plan says this service is not covered under your benefit package.
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-approve gingivectomy or gingivoplasty to allow access for restorative procedure (D4212) of tooth #'s 10 and 11.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 2, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 service 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 physician's services provided on January 2, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio.
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 diagnosis of chronic ulcerative pancolitis without complications. He has not tried and failed the Plan's required drugs of Remicade or Inflectra and Stelara. The records do not show that the required drugs would be less effective or contraindicated; therefore, the Entyvio 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 Entyvio.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on January 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the vision services. You say that you were told this doctor was part of your network. The Plan denied your request. The Plan says that you use network providers to get their medical care and 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 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 the vision services provided on January 7, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued Skilled Nursing Facility (SNF) care after June 17, 2020.You askedthe Plan to pre-approveSNF care. You say that you need oxygen, a wheelchair, and a walker when you go home but do not have these items yet.The Plan denied your request. The Plan says the denial of authorization for continued SNF care after June 17, 2020 is correct.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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage ofSNF care have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued Skilled Nursing Facility (SNF) care after June 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wound care supplies over the allowed limit.
You asked the Plan to pre-approve wound care supplies over the allowed limit. You say that you need wound care supplies. The Plan denied your request. The Plan says no clinical information was submitted to indicate why you need an amount over the allowed limit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. The record does not show why you need an amount of wound care supplies that is over the allowed amount. Based on this information, we decided that Medicare rules for coverage of wound care supplies over the allowed limit have not been met. Therefore, we decided that the Plan does not have to pre-approve wound care supplies over the allowed limit.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on October 18, 2019.You asked the Plan to pay for lab test. You say that you have submitted documentation to support the services performed.The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted did not include a physician order for this test.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab service denied by the Plan. Based on this information, we decided that Medicare rules for coverage of lab test have not been met.Therefore, we decided that the Plan does not have to pay for laboratory testing provided on October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an extended electroencephalogram (EEG) (95812) provided on July 9, 2019.
You asked the Plan to pay for an extended EEG. You say that the operative report supports this code. The Plan denied your request. The Plan says the medical records show that a different code was performed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95812 is electroencephalogram (EEG) extended monitoring; 41-60 minutes. We find that CPT code 95812 is not supported in the medical record. Specifically, the technical report states that code 95955, a non-cranial EEG, was performed. There is no documentation that an extended EEG was performed. Based on this information, we decided that Medicare rules for coverage of an extended EEG have not been met. Therefore, we decided that the Plan does not have to pay for an extended electroencephalogram (EEG) (95812) provided on July 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fordental custom abutment (D6057) and abutment supported crown (D6058) provided January 20, 2020.You asked the Plan to pay forthe dental services. You say that you were informed that this provider was in your dental plan only to find out the claim denied because they are not.The Plan denied your request. The Plan says implant services are not listed as covered services.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 pay fordental custom abutment (D6057) and abutment supported crown (D6058) provided January 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay for the ambulance services. You say that on the dates of service you had fallen and you could not get back up. You say that you called for the ambulance and the responders came and helped you off of the floor. You stated that you didn't need to go to the hospital and that you didn't know what else to do. You say that you do not have the money for the bill and the cost would be a burden for you. You stated that you do not walk so well anymore and you were told by your doctor to call the ambulance when you fall.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 December 30, 2019, January 1, 2020 and January 13, 2020. 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.