Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a specialist visit (99203) provided June 29, 2020.
You asked the Plan to pay for the specialist visit. You say that the service should be covered as the deductible was met and the provider is a participating provider. The Plan denied your request. The Plan says the provider is out-of-network and the deductible was not met at the time services were rendered.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible for out-of-network specialist visits. The item or service you asked the Plan to pay for falls within the benefit category specialist visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for out-of-network specialist visits. This cost sharing is a contractual obligation that had not been met at the time the specialist visit was received on June 29, 2020. Therefore, we decided that the Plan does not have to pay for a specialist visit (99203) provided June 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture and a mandibular partial denture.
You asked the Plan to pre-approve the maxillary partial denture and mandibular partial denture. You say that you lost your previous partials. You also say that you need these dentures for your continued health, and you are unable to eat without them. The Plan denied your request. The Plan says these services are not covered benefits under your 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 pre-approve a maxillary partial denture and a mandibular partial denture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laboratory services to be provided by the out-of-network provider.
You asked the Plan to pre-approve the laboratory services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve laboratory services to be provided by the out-of-network provider.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for coronary artery bypass grafting. Medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897) for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the use of this drug requires a diagnosis of non-metastatic prostate cancer.
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 requested use of Prolia is not FDA approved or supported in any of the CMS approved compendia. Therefore, the submitted documentation does not support that Prolia is reasonable and necessary for the enrollee. The submitted documentation does not support that the drug is safe and effective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897) for the enrollee.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for lab services (80061) provided April 30, 2019.
You asked the Plan to pay for the lab services. You say that the service should be covered and you aren't sure why you are receiving a bill from the lab. The Plan denied your request. The Plan says that the test is non-covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan has cited Local Coverage Determination (LCD): Frequency of Laboratory Tests (L35099) in their decision to deny the claim. The plan has not provided any record of when the enrollee last received this service. Documentation provided to the IRE was limited to the plan's determination letter and screen captures of the plan's claim processing system. No clinical records were provided and no reference to previous claims for this service were provided. Without this information, the IRE cannot determine if the lab services performed exceed the frequency permitted under Medicare rules. Therefore, we decided that the Plan has to pay for lab services (80061) provided April 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a low dose CT scan of the lungs provided to the enrollee on February 10, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says non-contracted providers are required to furnish necessary information to the healthplan when requested.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. A non-contract provider must provide enough records to determine medical necessity. We looked at the file and Medicare Rules. Based on this information, we decided that Medicare rules for the services at issue have not been met. Specifically, the case file did not contain medical records for the billed services. Without the medical records, the billed services cannot be verified. 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 a low dose CT scan of the lungs provided to the enrollee on February 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the PPE.
You asked the Plan to pre-approve the PPE. The Plan denied your request. The Plan says this 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 pre-approve the PPE.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on June 10, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that the oral evaluation was necessary in order to determine how to treat you for the pain you were in. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit 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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on June 10, 2020.
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 you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical problems are stable. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive therapy program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
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 reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for pneumonia and a urinary tract infection. The enrollee has a tracheotomy and is on a nighttime ventilator at baseline. There is no expectation of full ventilator liberation and decannulation. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Darbepoetin (Aranesp) injections for the enrollee.
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says that the ferritin and/or transferrin saturation levels were not received.
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 injections. Our reviewer says that the requested injection is medically reasonable and necessary. Our physician reviewer found J0881 - Darbepoetin (Aranesp) is requested to treat anemia related to chemotherapy and multiple co-morbidities in this 86 year old enrollee with recently diagnosed non-Hodgkin's lymphoma/diffuse large B-cell lymphoma. It is noted that ongoing chemotherapy with RCHOP is planned for at least 6 courses. The enrollee had course #3 on December 3, 2020. Based on a review of the documentation provided including, but not limited to, hemoglobin/hematocrit, pre-chemotherapy iron studies and bone marrow examination, and serum creatinine, the documentation supports that Darbepoetin (Aranesp) is medically reasonable and necessary for this enrollee, and that the requested treatment will be safe and likely effective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injections have been met. Therefore, we decided that the Plan has to pre-approve Darbepoetin (Aranesp) injections for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve the Keytruda injections (J9271).
You asked the Plan to pre-approve Keytruda. You say that the service is medically necessary for your condition. The Plan denied your request. The Plan says that this patient does not meet the recommended criteria for using Keytruda.
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 Keytruda. Our reviewer says that the service is medically necessary. Our physician reviewer found Keytruda is approved for first line treatment of the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have been met. Therefore, we decided that the Plan has to pre-approve the Keytruda injections (J9271).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the information submitted does not meet the medical necessity guidelines for coverage.
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 the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered or that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Without the support of the documentation, Gel-One is not approved as step criteria have not been met. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Shingrix vial kit.
You asked the Plan to pre-approve Shingrix. You say that this service is medically necessary. The Plan denied your request. The Plan says this is not a medical necessity denial. Medicare says Part B programs can only provide limited benefits for prescription drugs.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Shingrix. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to Shingrix. Therefore, we decided that the Plan does not have to pre-approve the Shingrix vial kit.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided on February 17, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service provided is not a covered benefit under your contractual policy as you did not receive transport.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 17, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided on February 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefabricated post and core in addition to crown and retreatment of previous root canal therapy.
You asked the Plan to pre-approve the post and core and retreatment of previous root canal therapy. The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit 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 pre-approve a prefabricated post and core in addition to crown and retreatment of previous root canal therapy.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Positron Emission Tomography/Computed Tomography (PET/CT) scan.
You asked the Plan to pre-approve PET/CT scan. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this test is not medically necessary.
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 PET/CT scan. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested PET scan. Our physician reviewer found the enrollee has had 3 PET/CT scans, and further follow-up can be done with Computed Tomography (CT). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PET/CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a Positron Emission Tomography/Computed Tomography (PET/CT) scan.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on October 17, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice selection at the time of service, this claim should be submitted to Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on October 17, 2019.