Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemolecular genetic testing for the enrollee.You asked the Plan to pre-approvethe testing. You say that this is needed to look for causes of an uncommon type of diabetes called maturity onset diabetes of the young (MODY).The Plan denied your request. The Plan says the enrollee does not have symptoms of diabetes such as excessive thirst, urination, or weight loss.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Weasked 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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found MODY is a rare genetic disease (with many sub-types) that is more likely to affect adolescents and young adults. This condition is rare in the enrollee's age group and typically presents with a sudden need for insulin treatment. The enrollee's medical records showed one blood sugar of 118 that was not fasting and thereby normal. The enrollee does not have symptoms of diabetes such as excessive thirst, urination or weight loss.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 testing have not been met.Therefore, we decided that the Plan does not have to pre-approvemolecular genetictesting for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on February 7, 2020.You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.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 servicesat 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 outpatient hospital services provided on February 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on November 8, 2019.You asked the Plan to pay for the services. You say that you cannot afford to pay the bill.The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on November 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 17, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on December 17, 2019.
Appeal type: Drugs
Decision: Partially Favorable

We decided that the Plan has to pre-approveDenosumab. We decided that the Plan does not have to pre-approveFulvestrant. You asked the Plan to pre-approveFulvestrantand Denosumab. You say that you would like the plan to reconsider their denial.The Plan says that the requested drugs are not 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-approveFulvestrant and Denosumab.We decided that the Planhas to pre-approveDenosumab. Our reviewer saysthat the documentation doessupport that the requested drug,Denosumabis medically reasonable or necessary. Our physician reviewer found that the enrollee has bilateral breast cancer. The enrollee was onZometa in past and changed to Denosumab due to worsening creatinine.Denoxumab is safe and effective and can continue for bone health.Consequently, the enrollee does meet criteria for this requested drug. Therefore, we decided that the Plan has to pre-approveDenosumab. We also decided that the Plandoes not have to pre-approveFulvestrant.Our reviewer says that the documentation does not support that the requested drug,Fulvestrant is medicallyreasonable or necessary.Our physician reviewer foundthat this drug is unlikely to be effective given progression of disease while receiving it.Consequently, the enrollee does not meet criteria for this requested drug. Therefore, we decided that the Plan does not have to pre-approveFulvestrant
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bevacizumab injections (J9035), eye drug injections (67028), scanning computerized ophthalmic diagnostic imaging (92133), and treatment of extensive or progressive retinopathy (67228).You asked the Plan to pre-approve the Bevacizumab injections, eye drug injections, scanning computerized ophthalmic diagnostic imaging, and treatment of extensive or progressive retinopathy. The Plan denied your request. The Plan says they are unable to determine medical necessity for this procedure due to the lack of information.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 Bevacizumab injections, eye drug injections, scanning computerized ophthalmic diagnostic imaging, and treatment of extensive or progressive retinopathy. Our reviewer says that the service does not meet the Plan's coverage criteria. Our physician reviewer found the enrollee is noted to have a choroidal mass, which, while touted as malignant, is not given a specific diagnosis (ex. melanoma). The prior authorization request touts diagnoses of retinal ischemia and retinal edema, but the documentation notes normal retinal vessels and normal retinas on examination. Our reviewer found that there is no documentation of a diagnosis of macularde generation. There is no documentation of a plan to provide Bevacizumab injections. Our physician reviewer also found that the documentation does not support that the requested Bevacizumab is medically necessary, reasonable, or planned.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 Bevacizumab injections, eye drug injections, scanning computerized ophthalmic diagnostic imaging, and treatment of extensive or progressive retinopathy have not been met.Therefore, we decided that the Plan does not have to pre-approve Bevacizumab injections (J9035), eye drug injections (67028), scanning computerized ophthalmic diagnostic imaging (92133), and treatment of extensive or progressive retinopathy (67228).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a balloon sinuplasty for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says the submitted radiologic is two years old, and therefore, not indicative of current status.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the most recent CT was done 2 years ago and her medical management has included nasal steroid sprays. Before proceeding with a sinus procedure, it is important to obtain accurate and recent imaging. This will not only delineate the enrollee's anatomy, but it would also give information regarding the extent of her sinusitis. It would be a disservice to the enrollee to operate on some diseased sinuses, but not all of them. Or, the enrollee's maxillary sinuses might have improved since 2018 and she may not need a sinus procedure. Therefore, she does not meet criteria for a balloon sinuplasty. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a balloon sinuplasty for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDurvalumab (Imfinzi).You asked the Plan to pre-approveImfinzi. The Plan denied your request. The Plan says the enrollee must not have had disease progression while on chemoradiation or after at least two cycles of chemotherapy and radiation.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Imfinzi. Our physician reviewer found that Imfinzi was requested for unresectable stage III non-small cell lung cancer (NSCLC) that has been treated with unspecified chemotherapy and radiation. There are no imaging reports or description of such imaging to determine whether there is disease progression since the treatment. The FDA indication is for patients without disease progression after platinum based chemotherapy and radiation for NSCLC. The compendia support the same indication. The submitted documents do not include the nature of the chemotherapy or imaging since he completed the treatment in May, 2020. The use is not listed as not indicated, not recommended or not supported for the requested use.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to pre-approveDurvalumab (Imfinzi).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the resin-based composites provided on February 11,
2020.
You asked the Plan to pay more for the resin-based composites. You say that you were informed that the
provider was in-network. You say that you are being wrongfully billed. The Plan denied your request. The Plan
says the claim processed correctly.
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 correctly processed the claim
for the out-of-network dental services. Therefore, we decided that the Plan does not have to pay more for the
resin-based composites provided on February 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from January 8, 2020 through February 25, 2020 provided by an in-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you thought you would not have to pay anything for these services as a hospital representative told you it was covered under your plan. The Plan denied your request. The Plan says the claims were processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received inpatient hospital care from January 8, 2020 through January 24, 2020 and February 20, 2020 through February 25, 2020 from an in-network provider. Your EOC states, enrollees must pay a $395 copayment per in-network inpatient hospital care admission. You had two hospitalizations and are asked to pay a $395 copayment for each admission. 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 inpatient hospital care from January 8, 2020 through February 25, 2020 provided by an in-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care from 11 AM on November 3, 2019 to 6:50 PM on November 5, 2019.
You asked the Plan to pay for inpatient care. You say that this was medically necessary. The Plan denied your request. The Plan says this was not authorized.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for inpatient care. Our reviewer says that the criteria for coverage of these services has not been met. Our physician reviewer found the records show that the enrollee was downgraded out of the intensive care unit and cleared for transfer to a Plan facility on November 2, 2019. She did not have any complications overnight and is stable for transfer at 10:59 AM on November 3, 2019. There was no documentation provided necessitating post-stabilization care services 11 AM on November 3, 2019 to 6:50 PM on November 5, 2019. The review indicates that did not the treating physician document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient care from 11 AM on November 3, 2019 to 6:50 PM on November 5, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a Positron Emission Tomography (PET) scan (78816).You asked the Plan to pre-approve the PET scan. You say that the PET scan is medically necessary.The Plan denied your request. The Plan says that coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our reviewer says that the requested PET scan is medically necessary. Our physician reviewer found the PET scan is medically appropriate for a patient post-treatment with rising PSA levels.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 PET scan have been met.Therefore, we decided that the Plan has to pre-approve a Positron Emission Tomography(PET) scan (78816).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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for assisted living services provided on February 7, 2020 by an out of network (OON) provider.You asked the Plan to pay for assisted living services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not 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 assisted living services provided on February 7, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the wound care provided from March 15, 2019 to April 9, 2020.You asked the Plan to waive the copayments for the wound care. You say that you did not received the wound care at a hospital, emergency room, urgent care facility or testing lab. You say you are questioning the different amounts that were charged.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 $250 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a total of $834for the wound care. The wound care falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows you were billed by an outpatient hospital. 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 the wound care provided from March 15, 2019 to April 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of a foot infection (28002) provided on November 7, 2019.
You asked the Plan to pay for the treatment of a foot infection. You say that this is documented in the records. The Plan denied your request. The Plan says the records are insufficient to corroborate this service.
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 28002 is incision and drainage below fascia, with or without tendon sheath involvement, foot; single bursal space. We find that CPT code 28002 is not supported in the medical record. Specifically, the records do not document whether incision and drainage occurred below the fascia. Without this information, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the treatment of a foot infection have not been met. Therefore, we decided that the Plan does not have to pay for the treatment of a foot infection (28002) provided on November 7, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemultifocal lens implant (presbyopia-correcting lenses).You asked the Plan to pre-approvemultifocal lens implant (presbyopia-correcting lenses). You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an P-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a conventional IOL. While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting feature of an IOL.Therefore, we decided that the Plan does not have to pre-approvemultifocal lens implant (presbyopia-correcting lenses).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the IRF admission is medically necessary.The Plan denied your request. The Plan says your needs can be met at a different level of care.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 the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at an alternate level of care.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 decidedthat the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.