Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse for services provided on January 1, 2019.
You asked the Plan to reimburse for the services. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says rowing is not a covered benefit toward your Wellness Allowance.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's rules for coverage of gym benefits have not been met because rowing is not a covered benefit toward your Wellness Allowance. Therefore, we decided that the Plan does not have to reimburse for services provided on January 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0482) provided to the enrollee on September 16, 2019.
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 according to the claims data available at the time of the review, the plan was unable to discover any evidence of an established relationship between the member and the ordering physician.
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 the denied codes is: CPT 80307: Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, by instrument chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (DAT, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service (maps to 80301, 80302, 80303, 80304 and G0479)
HCPCS G0482: Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed 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. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found an order form was submitted without the enrollee's name and no evidence of a relationship with the prescribing physician was described in the provided records in general to support this request. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0482) provided to the enrollee on September 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says based on Medicare
guidelines, the enrollee does not meet the requirements for approval.
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 that the enrollee does not meet criteria for IRF admission. The enrollee was
medically stable with no evidence of need for supervision by PMR physician or needs acute rehab nursing care.
Functionally given her current level, she does not require IRF level of therapies. The enrollee may benefit from
further physical therapy and occupational therapy but does not require an intensive therapy program. IRF
admission is not medically necessary based on the enrollee's current functional status and medical stability.
The enrollee will definitely benefit from a lower intensity rehab such as in an SNF. The enrollee's rehab needs
can be met at a lower intensity setting such as in an SNF.
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the plan will approve a SNF admission if requested by the physician.
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 there is no evidence of need for supervision by a PMR physician. There is no need
for acute rehab nursing care. Functionally, she does not require the IRF level of therapy. The enrollee may
benefit from further PT and an OT but does not require an intensive therapy program. IRF admission is not
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 IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from September 17, 2019 through November 5, 2019 provided by an out-of-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing the member's cost-share responsibility for the services the member received. The Plan denied your request. The Plan says the claims were processed accordingly with your 2019 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 shows that you were admitted on September 17, 2019 and discharged on September 21, 2019. You were asked to pay a $264 copayment per day from September 17, 2019 through September 20, 2019, days 1-4 of your inpatient hospital care. You were discharged on September 21, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $264 copayment per day required for days 1-7. Furthermore, you were admitted on October 18, 2019 and discharged on October 24, 2019. You were asked to pay a $264 copayment per day from October 18, 2019 through October 23, 2019, days 1-6 of your inpatient hospital care. You were discharged on October 24, 2019 and there was no copayment charge for the day of discharge. You were admitted on October 28, 2019 and discharged on November 5, 2019. The Plan is charging you for six (6) days instead of seven (7). This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care from September 17, 2019 through November 5, 2019 provided by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecontinued skilled nursing facility (SNF) services for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansayswhile the enrollee may benefit from continuing physical and occupational therapy, the records do not support the need for daily therapy on an inpatient basis.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 the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity ofservice criteria for an inpatient basis in a skilled nursing facility 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 the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvecontinued skilled nursing facility (SNF) services for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and accessories to be provided by an out of network (OON) provider.You asked the Plan to pre-approve a power wheelchair and accessories. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested items can be provided by a network provider.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 rules also state that for equipment to be covered, it must be appropriate and needed for use inside the home.We note that the requested power wheelchair has special features that is better suited for the enrollee's environment not always being on even ground, however, this is a convenience feature of the wheelchair that is not covered. In addition, the specific requested power wheelchair may be helpful but neither Medicare nor the Plan covers equipment for use outside the home. 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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveseat lift mechanism, electric, any type (E0627).You asked the Plan to pre-approvethe seat lift mechanism. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says no clinical was submitted from provider to substantiate the need for the device.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 seat lift mechanism. Our physician reviewer found the medical records provided do not meet the requirements listed in the LCD/PIM for Medicare coverage for the seat lift mechanism, electric, any type (E0627). You do nothave severe arthritis of the hip or knee or a severe neuromuscular disease. The documentation does not support that the requested device will effect improvement, or arrest or retard deterioration in your condition. You arecapable of standing up from a regular armchair or any chair in your home per the certificate of medical necessity. You areable to ambulate once standing.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 seat lift mechanism have not been met.Therefore, we decided that the Plan does not have to pre-approveseat lift mechanism, electric, any type (E0627).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the resin-based composites provided on March 3, 2020.
You asked the Plan to pay more for the resin-based composites. You say that you didn't know the dental office
was not in-network. You say that you didn't know your dental was cancelled. The Plan denied your request.
The Plan says the claim reprocessed to reflect your in-network 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 Plan also has a maximum benefit
of 2 fillings per calendar year. The Plan reprocessed and paid for 2 fillings provided on March 3, 2020 at the innetwork
rate, which exhausted your benefit. The remaining resin-based composite was denied because your
benefit was exhausted. Therefore, we decided that the Plan does not have to pay more for the resin-based
composites provided on March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7323).
You asked the Plan to pre-approve Euflexxa. 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 this treatment will only be covered for the treatment of pain in osteoarthritis of the knee. 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 Euflexxa. Our reviewer says that the services are not medically necessary. Our physician reviewer found this would be an off-label use of the medication and is not supported by rigorous clinical trials. The request does not meet the criteria for coverage. Therefore, the request 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extraction of teeth #7, 8, 9, 10, 11, 12, 13, 14, 20, 21,
22, 23, 24, 25, 26, 27, 28 and 29 (D7210), deep sedation/general anesthesia - first 15 minutes (D9222), deep
sedation/general anesthesia - each subsequent 15 minute increment (D9223), and therapeutic parenteral drug
(D9610).
You asked the Plan to pre-approve extraction of teeth #7, 8, 9, 10, 11, 12, 13, 14, 20, 21, 22, 23, 24, 25, 26, 27,
28 and 29, deep sedation/general anesthesia - first 15 minutes, deep sedation/general anesthesia - each
subsequent 15 minute increment, and therapeutic parenteral drug. You say that the services are necessary. The
Plan denied your request. The Plan says the benefits have either been exhausted or 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. The Plan covers 3 nonsurgical
or surgical extractions per calendar year.
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of extraction of teeth #7, 8, 9, 10, 11, 12, 13, 14, 20, 21, 22, 23, 24, 25, 26, 27, 28 and 29, deep
sedation/general anesthesia - first 15 minutes, deep sedation/general anesthesia - each subsequent 15 minute
increment, and therapeutic parenteral drug have not been met. Therefore, we decided that the Plan does not
have to pre-approve extraction of teeth #7, 8, 9, 10, 11, 12, 13, 14, 20, 21, 22, 23, 24, 25, 26, 27, 28 and 29
(D7210), deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia - each
subsequent 15 minute increment (D9223), and therapeutic parenteral drug (D9610).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve use of Imfinzi.
You asked the Plan to pre-approve Imfinzi. You say that the enrollee has stage III lung cancer and is in need of
this chemotherapy. The Plan denied your request. The Plan says that the denial of authorization for Imfinzi is
correct, because Imfinzi is not FDA-approved or recognized by Medicare compendia for treatment of the
enrollee's condition.
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
enrollee meets the Medicare criteria for the requested use of Imfinzi. Our physician reviewer found the use of
Imfinzi is FDA-approved for the enrollee's diagnosis. The enrollee is being treated as a stage III and completed
weekly chemotherapy and radiation therapy. The documentation supports that the requested Imfinzi is safe and
effective and otherwise reasonable and necessary 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 Imfinzi have been met. Therefore, we decided that the Plan has to pre-approve
use of Imfinzi.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric hospital services provided to the enrollee from November 8, 2019 to December 17, 2019.You asked the Plan to pay for the inpatient psychiatric hospital services. You say that these services were medically necessary.The Plan denied your request. The Plan says that as of 11/14/19, the enrollee had no acute symptoms that require 24 hour care.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services. Our reviewer says that the inpatient psychiatric hospital services were not medically reasonable and necessary for the enrollee in this case. This enrollee did not appear to require inpatient mental health treatment as she was not a danger to herself or others and was cooperative with care without any aggressive behaviors. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. We are unable to find an individualized treatment plan; however,the entire record is not present. It did appear that the records were supervised and evaluated by a physician. She is noted to be cooperative and compliant with treatment while not showing any aggressive behaviors. Our physician reviewer found that this patient does not meet criteria for acute inpatient mental health treatment as she was not shown to be a danger to herself or others and had no auditory or visual hallucinations.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 inpatient psychiatric hospital services have not been met.Therefore, we decided that the Plan does not have to pay for the inpatient psychiatric hospital services provided to the enrollee from November 8, 2019 to December 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora Chest X-ray (71045) provided October 14, 2019.You asked the Plan to waive the copayment forthe Chest X-ray. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct cost sharing was applied.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 $150 copayment for x-rays performed in the outpatient hospital setting. You have been asked to pay the Medicare allowed amount of $64.27 for the Chest X-ray. The chest x-ray was performed in the outpatient hospital setting. In this case, the allowed amount was less than the $150 copayment noted in the plan contract. 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 fora Chest X-ray (71045) provided October 14, 2019.