Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that intensive physical therapy and occupational therapy are medically necessary for this enrollee to increase independence and return to prior level of function.The Plan denied your request. The Plan says you can safely receive services you need in lower level of care such as skilled nursing facility or home with home health and home physical therapy.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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy or occupational therapy but the enrollee does not require this on an intensive rehabilitation facility therapy program level in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided November 7, 2019. You asked the Plan to pay for the dental services. You say that you made it very clear that you were only covered for a general cleaning and asked the staff to make sure the dentist only does that. You cannot afford to pay for services that are not covered. The Plan denied your request. The Plan says the service is not a covered benefit. 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 periodontal maintenance (D4910) provided November 7, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 19, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 September 19, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services.
You asked the Plan to pay for the paramedic intercept services. You say that you want to appeal the Plan's denial of payment. You say that you should only have to pay a $75.00 co-payment for the services. The Plan denied your request. The Plan says this item is not a covered benefit.
The rules say that Medicare pays for advanced life support (ALS) paramedic intercept services only when the services are furnished in a rural area. The paramedic intercept services at issue in this appeal were not furnished in a rural area. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durvalumab (Imfinzi).
You asked the Plan to pre-approve Durvalumab. The Plan denied your request. The Plan says this is 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 Durvalumab. Our reviewer says that Durvalumab is not medically reasonable and necessary in this case. Our physician reviewer found that Durvalumab is FDA approved for the treatment of unresectable stage III non-small cell lung cancer which has not progressed following concurrent platinum-based chemotherapy and radiation therapy. This enrollee with oligometastatic disease has a possible metastatic lesion in the right pelvis for which a biopsy is planned. Should this be consistent with metastatic disease then the use of Durvalumab would not be indicated. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durvalumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Durvalumab (Imfinzi).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care evaluation and management services (99291) provided on April 4, 2019.You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says a review of the medical records submitted determined that the billed services were not supported.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 99291 is critical care services, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.We find that CPT code 99291 is not supported by the documentation in the case file. Specifically, CPT code 99291 is a time-based code. In order to bill CPT code 99291, the documentation must note that30-74minutes was spent providing services to the enrollee. The medical records provided in the case file do not note how much time was spent providing these services to the enrollee. As such, the provided documentation does not support the billing of CPT code 99291.Therefore, we decided that the Plan does not have to pay for the critical care evaluation and management services (99291) provided on April 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit providedon June 1, 2019.You asked the Plan to pay for the domiciliary, rest home visit. 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 a domiciliary, rest home visit provided on June 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and panoramic x-ray provided on October 21, 2019.
You asked the Plan to pay for the comprehensive oral evaluation and panoramic x-ray. You say that you did not need to see a dentist but still went for a checkup. You also say that the Plan told you to get a checkup because it is one of your benefits. The Plan denied your request. The Plan says these services are not covered under 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 comprehensive oral evaluation and panoramic x-ray provided on October 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan.
You asked the Plan to pre-approve Rituxan. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of Rituxan is not supported for the enrollee's condition.
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 Rituxan. Our reviewer says that Rituxan is not medically necessary at this time. Our physician reviewer found according to the provided records, Rituxan was chosen over cyclophosphamide as they preferred "minimizing pill burden." However, this isn't a medical contraindication or intolerance sufficient enough to justify Rituxan use over the cyclophosphamide. Rituxan would not likely be significantly more effective or safer compared to cyclophosphamide. Cyclophosphamide may be more effective when combined with corticosteroids. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rituxan have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituxan.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient services provided on January 16, 2019 to January 17, 2019 by an out of network (OON) provider.You asked the Plan to pay foroutpatient services. You say that these services were medically necessary and you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained 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 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 foroutpatient services provided on January 16, 2019 to January 17, 2019 by an out of network (OON) provider.
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 services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, the member is mostly MODERATE to MAX assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy may be more appropriate. It is not clear the member would be able to fully benefit and/or participate in an IRF 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 decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. You say that this is medically necessary.The Plan denied your request. The Plan says that you have no skilled nursing needs that might require a SNF.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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the colorectal screening on October 8, 2019.
You asked the Plan to waive the deductible for the colorectal screening. You say that this should be approved at 100% by the health plan. 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 $5,500 deductible that applies towards the colorectal screening. The colorectal screening you asked the Plan to waive the deductible for falls within the "Colorectal cancer screening" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $5,500 deductible that applies towards the colorectal screening. This cost sharing is a contractual obligation that had not been met at the time the colorectal screening was received on October 8, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the colorectal screening on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox (J0585).
You asked the Plan to pre-approve Botox (J0585). You say that the requested Botox is medically necessary. The Plan denied your request. The Plan says the requested Botox is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Botox (J0585). Our reviewer says that the requested Botox is not medically necessary. Our physician reviewer found the enrollee is with diagnoses of Gastroparesis and Nausea with vomiting, unspecified. Her past medical history includes hiatal hernia repair in 2018. Causality between pyloric dysfunction and symptoms of gastroparesis has not been adequately demonstrated. Although several open-label studies showed initial promise, 2 randomized clinical trials have failed to demonstrate a difference in clinical outcomes between botulinum toxin and placebo in the treatment of gastroparesis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox (J0585) have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox (J0585).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approveleft heart catheterization (93452).You asked the Plan to pre-approveleft heart catheterization. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that left heart catheterization is covered when specific criteria is 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 left heart catheterization. Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the records you have increased coronary risk, unexplained exertional dyspnea, no chest pain, no cardiac exam abnormalities, no ischemic electrocardiographic changes and no evidence of coronary ischemia on a recent technically adequate pharmacologic nuclear stress test. In this circumstance the cause of your exertional dyspnea is not certain but since there is no evidence of ischemia on noninvasive evaluation the records do not support the medical necessity for coronary angiography at this time before other causes of dyspnea are first ruled out such as pulmonary hypertension or worsening dynamic left ventricular outflow tract (LVOT) obstruction as reported on the echocardiogram.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of left heart catheterization have not been met.Therefore, we decided that the Plan does not have to pre-approveleft heart catheterization (93452).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided October 11, 2019 to October 14, 2019.
You asked the Plan to pay for inpatient hospital services. You say that you were there against your will and there was no valid reason for you to be hospitalized. Please do not hold you responsible for this bill. The Plan denied your request. The Plan says the facility is a non-Medicare approved/certified freestanding emergency facility. It is not a hospital and is not affiliated with a hospital and as a result is unable to obtain Medicare approval/certification.
The Plan must follow Medicare rules. The rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider and supplier enroll in the Medicare program per Chapter 15, Section 15.1 of the Medicare Program Integrity Manual. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided October 11, 2019 to October 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on July 8, 2019 by an out of network (OON) provider.You asked the Plan to pay for the vision services. You say that the medical records provided support the necessity of the services in dispute.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to 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 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 forthe vision services provided on July 8, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Imfinzi.
You asked the Plan to pre-approve Imfinzi. You say that the requested Imfinzi is medically necessary. The Plan denied your request. The Plan says the requested Imfinzi is not medically necessary.
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 reviewer says that the requested Imfinzi is not medically necessary. Our physician reviewer found the enrollee is with stage III non-small cell lung cancer. Imfinzi is FDA-approved for the enrollee's diagnosis. Although the diagnosis is FDA approved the enrollee did not receive platinum based therapy for original therapy. FDA approval for lung cancer is based on not progressing after prior treatment with a platinum base chemotherapy and radiation. This enrollee does not meet this criteria as he did not receive chemotherapy. 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-approve Imfinzi