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

We decided that the Plan does not have to waive the copayment for an ultrasound provided on August 2, 2019.You asked the Plan to waive the copayment foran ultrasound. You say that you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $100 copayment for ultrasounds. You have been asked to pay the allowed amount of $61.31, which is less than the $100 copayment for an ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran ultrasound provided on August 2, 2019
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xeljanz for "the enrollee". You asked the Plan topre-approve Xeljanz. You say that the enrollee has experienced inadequate responses to other drugs.The Plan denied your request. The Plan says Xeljanz is not covered under the Part B benefit.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-approveXeljanz for "the enrollee". Benefits for Xeljanzmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.You asked the Plan to pre-approve the LTACH services. You say that the enrollee has a declining condition and requires more respiratory care.The Plan denied your request. The Plan says the ongoing consultation services to ensure clinical stability are best handled in the current setting.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for end-stage COPD. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.We looked at this physician's review, the file, and Medicare rules. Based on this information, wedecided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex spacer.You asked the Plan to pre-approvethese services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has back pain. The requested Vertiflex spacer is considered experimental in nature, as more research is needed. The services are not reasonable or medically necessary at this time.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-approvea Vertiflex spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to "the beneficiary" by an out-of-network provider on August 9, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency 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 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 forthe medical services provided to "the beneficiary" by an out-of-network provider on August 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Colchicine.You asked the Plan to pre-approve Colchicine. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not a covered benefit.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-approveColchicine.Benefits for Colchicinemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve16 additional extractions (41899). You asked the Plan to pre-approve 16 additional extractions. You say that you have cancer. You also say that your teeth are causing a lot of infection in your mouth. The Plan denied your request. The Plan says the frequency limit for extractions has been reached. The Plan also says only 2 extractions are covered per calendar year.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 and extractionsare a covered service, the frequency limit has been reached. The record shows that the Plan has already approved 2 extractions.Therefore, we decided that the Plan does not have to pre-approve16 additional extractions (41899).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methylphenid tablets 5mg.You asked the Plan to pre-approve Methylphenid tablets. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says Methylphenid tablets are not covered under the enrollee's Medicare Part B benefit.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 Methylphenid tablets 5mg.Benefits for Methylphenid tablets 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forcomplex repairs (13121 and 13132) provided on July 9, 2019.You asked thePlan to pay forcomplex repairs. You say that the correct CPT codes were used.The Plan denied your request. The Plan says there are more appropriate CPT codes for the services 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 13121 is repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm and 13132 is repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm.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 therequest to pay for complex repairs. Our reviewer says that CPT codes 13121 and 13132 are not supported by the record submitted. Our physician reviewer found the documentation states that multilayered closure was performed. According to CPT rules, this alone does not meet the requirements for reporting a complex closure. The record does not contain evidence that a complex closure was performed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of complex repairs have not been met.Therefore, we decided that the Plan does not have to pay forcomplex repairs (13121 and 13132) provided on July 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveProcrit.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthe use of this drug in this case requires iron status been evaluated and sufficient iron levels will be maintained in the patient prior to initiation of therapy and continuation of therapy.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the use of Procrit requires iron status been evaluated and sufficient iron levels will be maintained in the patient prior to initiation of therapy and continuation of therapy (i.e. transferrin saturation should be at least 20% OR ferritin at least 100ng/mL within the last 4 months; applies to most recent results). Step therapy criteria must also be met. There is no documentation indicating that the enrollee has tried and failed a course of Retacrit or that this medication would not be as effective or have adverse effects. The review has determined that the documentation does not support that the Procrit is medically reasonable and necessary for you. The documentation does not support that the Procrit is safe and effective for you at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met.Therefore, we decided that the Plandoes not haveto pre-approveProcrit.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveMRA of the head for the enrollee.You asked the Planto pre-approvethe imaging. You say that this is medically necessary.The Plandenied your request. The Plansaysadvanced imaging of the head is not supported in the absence of clinical evidence of intracranial vascular disease.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 imaging. Our reviewer says that the requested MRA is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has stable small vessel ischemic disease on brain MRA with no documented acute neurologic change and a normal neurologic physical exam abnormalities. In this circumstance, the documentation does not support the medical necessity for a repeat brain MRA. Moreover, aggressive risk factor modification is recommended regardless of any potential change on brain MRA.We looked at thisphysician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the imaging have not been met.Therefore, we decided that the Plandoes not haveto pre-approveMRA of the head for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power operated vehicle.You asked the Plan to pre-approvea power operated vehicle (scooter). You say that the approved power wheelchair is too heavy and big, and you do not have the copayment.The Plan denied your request. The Plan says you were approved for a power wheelchair based on a seating specialistassessment.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that you cannot safely operate the PMD being requested. The assessment shows a scooterwas ruled outdue to weakness in your upper and lower extremities, and poor balanceand seating. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approvea power operated vehicle.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided to the enrollee May 30, 2019, and May 31, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the primary carrier's payment is higher than the Medicare allowable fee maximum.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plancan direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has determined that the primary insurer has paid up to the limits of its coverage. As the secondary insurer, we decided that the Plan does not have to make additional payment for the services provided to the enrollee on May 30, 2019, and May 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 24, 2019 by out of network provider.You asked the Plan to pay for the CT Scans. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says prior authorization is required for advanced imaging services.Medicare rules say that plans can require enrollees to obtain authorization before receiving services. The Health Plan Contract also says that prior authorization is required for certain outpatient diagnostic tests.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 on May 24, 2019 by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit for the enrollee.You asked the Plan to pre-approve Procrit. You say that this is medically necessary.The Plan denied your request. The Plan says that they do not see that the enrollee's blood iron level is adequate at the present time.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 Procrit. Our reviewer says that Procrit is not medically reasonable and necessary for the enrollee in this case. Medicare requires that patients have adequate iron stores prior to initiation of Procrit. This patient has a ferritin of 17 and levels should be 100 or more. In addition, hemoglobin should be less than 10 prior to initiation of Procrit. Our physician reviewer found the enrollee's condition does not meet criteria for coverage of Procrit.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Procrit have not been met.Therefore, we decided that the Plan does not have to pre-approveProcrit for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay fora domiciliary or rest home visit for the evaluation and management of an established patient (99334) provided on December 21, 2018 by out of network provider.You asked the Plan to pay fora domiciliary or rest home visit for the evaluation and management of an established patient. You say that the plan denied the claim due to no authorization on file. You say your provider treated the member and they cannot deny any medical service that areessential forpatient health treatment. You are requesting a review of the claim and have it retro-authorized and process the payment.The Plan denied your request. The Plan says the non-urgent services were not authorized because the provider is a non-network provider with the member's health plan, and the member self-directed. The Plan says the member's primary care physician (PCP) did not refer for services. The health plan requires utilization of network providers when possible and availableand 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 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 fora domiciliary or rest home visit for the evaluation 
and management of an established patient (99334) provided on December 21, 2018 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee will receive a more aggressive complex care to maximize his progress.The Plandenied your request. The Plan says the enrollee still needs acute care in the acute hospital setting.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our physicianreviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH)for a septic joint and acute renal failure. The enrollee is to receive a prolonged course of antibiotics and ongoing hemodialysis. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for 3 units of procedure code 96375 provided on March 21, 2019.You asked the Plan to pay forthe services provided. The Plan denied your request. The Plan says that the documentation does not support the units billed.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 96375 is Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure). 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 services provided. Our physician reviewer found that the enrollee was seen for an Infed infusion. She also received by IV push Benadryl (from 12:30-12:34 PM), Heparin (from 4:43 to 4:47 PM) and Zofran (from 4:38-4:42 PM). The use of code 96375 (3 units) is supported by the medical records.We looked atthis physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services provided have been met. Therefore, we decided that the Plan has to pay for3 units of procedure code 96375 provided on March 21, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab testing provided on September 19, 2019.You asked the Planto pay forthe lab testing. You say that this is medically necessary.The Plandenied your request. The Plan sayspreventative vitamin assay and metabolic function tests are not a covered benefit. Medicare considers vitamin assay panels (more than one vitamin assay) a screening procedure and therefore, noncovered.The Plan must follow Medicare rules. Medicare rules say that providers must submit sufficient documentation to support that Medicare coverage criteria have been met.In this case, no progress notes from the ordering provider have been submitted. Without this documentation, it cannot be confirmed that coverage criteria are met.Therefore, we decided that the Plandoes not haveto pay forthe lab testing provided on September 19, 2019