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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower 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. 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 a lower level of care. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for IRF 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-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) on tooth #20 provided on April 30, 2019. 
 
You asked the Plan to pay for the crown. The Plan denied your request. The Plan says you would like this 
service to be reprocessed for payment. 
 
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 Plan covers the crown 
when the services are medically necessary and reasonable.  
 
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 the crown. Our reviewer says that the crown 
was not medically reasonable and necessary. Our physician reviewer found there was no indication regarding 
recurrent decay or defects in the existing crown on tooth #20 to warrant a replacement crown (D2740). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have 
to pay for the crown (D2740) on tooth #20 provided on April 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDexamethasone.You asked the Plan to pre-approveDexamethasone. You say that the medication is necessary.The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugsrequested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveDexamethasone.Benefits for Dexamethasonemay 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 Hyalgan (J7321). 
 
You asked the Plan to pre-approve Hyalgan. You say that the enrollee has bad osteoarthritis in both knees, and 
is hoping to find relief. The Plan denied your request. The Plan says the enrollee has not tried and failed the 
preferred step therapy device(s) Monovisc and Orthovisc. The Plan also says that there is no indication that the 
preferred agent(s) would likely be less effective, and/or cause adverse effects for the enrollee. 
 
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 Hyalgan. Our reviewer says that 
Hyalgan (J7321) is not medically reasonable and necessary for the enrollee. Our physician reviewer found 
based on the medical records provided the patient has not tried and failed the required drugs, Orthovisc and 
Monovisc. Our reveiwer also found that there is no indication that the Plan's required drug(s) would likely be 
less effective and/or likely have adverse effects 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan (J7321).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral sacroiliac joint injections (27096). You asked the Plan to pre-approve bilateral sacroiliac joint injections. 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 follows Medicare rules. Medicare rules say that Injection Tendon Sheath, Ligament, Ganglion Cyst, Carpal and Tarsal Tunnel are covered when specific information 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 bilateral sacroiliac joint injections. Our reviewer says that the services are not medically necessary. Our physician reviewer found the request does not meet the criteria and therefore, is considered not medically reasonable or 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 bilateral sacroiliac joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral sacroiliac joint injections (27096).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) of the abdominal aorta and bilateral iliofemoral lower extremity runoff (75635). You asked the Plan to pre-approve a CTA of the abdominal aorta and bilateral iliofemoral lower extremity runoff. 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. 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 a CTA of the abdominal aorta and bilateral iliofemoral lower extremity runoff. Our reviewer says that the services are not medically necessary. Our physician reviewer found absent unexpected changes in aneurysm size, plan for surgical intervention, peripheral vascular compromise etc. the medical necessity of CTA has not been established. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CTA of the abdominal aorta and bilateral iliofemoral lower extremity runoff have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) of the abdominal aorta and bilateral iliofemoral lower extremity runoff (75635).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CXBladder test provided to the enrollee on July 14, 2020. 
 
You asked the Plan to pay for the test. You say that this service was medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
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 pay for the test. Our reviewer says that the requested 
services are not considered medically reasonable and necessary in this case. Our physician reviewer found the 
case file contains a Statement of Medical Necessity which cites 'Detection of Urothelial Carcinoma' and 
'Hematuria Investigation' as the reasons for the testing. The case file does not contain clinical medical records. 
The documentation is insufficient to demonstrate that the information will likely improve this enrollee's 
outcome, and/or change physician care and treatment of 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 the test have not been met. Therefore, we decided that the Plan does not have to 
pay for the CXBladder test provided to the enrollee on July 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services coded A0427 and mileage coded 
A0425 provided on July 23, 2020. 
 
You asked the Plan to pay for the ambulance services and mileage. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
We asked our coding 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 the ambulance services and mileage. Our 
reviewer says that the documentation does not support the services billed. Our coding reviewer found The 
medical records provided do not include documentation to verify that the enrollee's presenting symptoms meet 
the prudent layperson criteria for emergency care. The medical records provided does not support that other 
means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were 
contraindicated for the enrollee. The medical records provided do not include sufficient documentation to 
support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a 
fully-equipped ambulance can provide for safe transport on July 23, 2020. The medical records do not support 
that the ambulance transport was medically reasonable and necessary for the enrollee. 
 
We looked at this coder's review, the file, and Medicare rules. Per our coding reviewer, the services at issue in 
this appeal were not provided in an emergency or urgent care situation. These services were not provided by 
the Plan or through arrangements with them. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services and mileage have not been met. Therefore, we decided that the Plan does 
not have to pay for the ambulance services coded A0427 and mileage coded A0425 provided on July 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the surgical procedure provided on 
September 24, 2020. 
 
You asked the Plan to waive the copayment for the surgical procedure. You say that you have had this 
procedure before with no copayment. The Plan denied your request. The Plan says the medical notes confirm a 
surgical procedure and you have been charged this copayment correctly. 
 
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 $125 
copayment for Outpatient Surgery.  
 
You have been asked to pay a $125 copayment for the surgical procedure. The surgical procedure falls within 
the Outpatient Surgery benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the surgical 
procedure provided on September 24, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. The Plan denied your request. 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.Continued SNF services beyond December 17, 2020, were requested. 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 physician reviewer found that from a nursing perspective, you received oral medications, had stable vital signs, and were treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, you were at a maximal to depended level with functional mobility. You required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a 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 of SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on August 5, 2020, by an out-of-network provider.
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider and the services were not urgent or emergent, nor were they approved in advance.
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 had network providers available who could have provided 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 medical services provided to the enrollee on August 5, 2020, by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gammagard. 
 
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. Medicare rules say that IVIG is covered when specific 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of unspecified 
common variable immunodeficiency. There is no documentation of a significant deficiency in gammaglobulin 
levels prior to initial treatment. There are no records of any IgG levels since March 17, 2015. The criteria for 
coverage are not met and the Gammagard is therefore 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 Gammagard.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Tetanus, diphtheria toxoids and acellular pertussis (Tdap)
vaccine received on July 22, 2020.
You asked the Plan to pay for the Tdap vaccine. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services received are not a covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine.
The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine.
Therefore, we decided that the Plan does not have to pay for Tetanus, diphtheria toxoids and acellular pertussis
(Tdap) vaccine received on July 22, 2020.
Benefits for the Tdap vaccine 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Victoza 18MGg/3ML injection.
You asked the Plan to pre-approve the medication. You say that this medication has helped the enrollee manage their weight ad keeping their sugars under control. The Plan denied your request. The Plan says the drug is self-administered and not covered by 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 Victoza 18MGg/3ML injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care services provided on September 10, 2020.
You asked the Plan to waive the copayment for the urgent care services. You say that you called your doctor to make an appointment because you thought you had a sore throat. You state the doctor does not see patients unless it is an emergency and you went to urgent care. The Plan denied your request. The Plan says the claim was 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 the urgent care services on September 10, 2020. You are asked to pay a $40 copayment for the services. Your 2020 EOC states that enrollees must pay a $40 copayment for each urgently needed service visit. 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 the urgent care services provided on September 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder testing (0012M) provided on August 11, 2020. 
 
You asked the Plan to pay for CxBladder testing. You say that this was medically necessary. The Plan denied 
your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are 
non-covered. 
 
We looked at the file and Medicare rules. The test at issue is not covered. Based on this information, we 
decided that Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that 
the Plan does not have to pay for CxBladder testing (0012M) provided on August 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup services received on June 15, 2020. 
 
You asked the Plan to pay for the core buildup services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services received are 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 the core 
buildup services received on June 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forintraoral-periapical first x-ray (D0220) intraoral-periapical x-rays, each additional x-ray (D0230) provided September 16, 2020.You asked the Plan to pay forthe dental services. You say that you went to the dentist and was told they were in network. A week later you found out they were not in network. Now you have a bill that you can't pay.The Plan denied your request. The Plan says this service is not covered under the plan benefits.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 forintraoral-periapical first x-ray (D0220) intraoral-periapical x-rays, each additional x-ray (D0230) provided September 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not have to pre-approveEntresto.You asked the Planto pre-approveEntresto. You say that the enrollee needs to continue taking this medication.The Plandenied your request. The Plansays coverage of this medication is the responsibility of the enrollee's prescription drug plan.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 Entresto.Benefits for Entrestomay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.