Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve intermittent urinary catheter with insertion supplies (A4353).
You asked the Plan to pre-approve intermittent urinary catheter with insertion supplies (A4353). You say that the requested intermittent urinary catheter with insertion supplies are medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for the requested intermittent urinary catheter with insertion supplies.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 intermittent urinary catheter with insertion supplies (A4353). Our reviewer says that the requested intermittent urinary catheter with insertion supplies are medically necessary. Our physician reviewer found the enrollee is with neurogenic bladder as a result of paraplegia. He is also wheelchair bound. He performs intermittent self-catheterization due to urinary incontinence. Clean intermittent self-catheterization is considered the standard of care for paraplegics with neurogenic bladder when they are able to perform this. These patients are at high risk for complicated urinary tract infections. The enrollee meets criteria for the requested intermittent urinary catheter with insertion supplies in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intermittent urinary catheter with insertion supplies (A4353) have been met. Therefore, we decided that the Plan has to pre-approve intermittent urinary catheter with insertion supplies (A4353).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe LifeVestrented on August 29, 2019 from an in-network provider.You asked the Plan to waive the coinsurance forthe durable medical equipment (DME). You say that you did not buy the equipment and do not feel that you should have to pay a total of $2319.60 for a vest that your doctor required you wear prior to a procedure that you had.The Plan denied your request. The Plan says the claim was 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 show that you rented a LifeVest on August 29, 2019 from an in-network provider. You have been asked to pay 20% coinsurance of the allowed amount for durable medical equipment. The allowed amount is $2899.50. The total you owe is $579.90 ($2899.50 x 20% = $579.90). 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 coinsurance forthe LifeVest rented on August 29, 2019 from an in-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.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 indenying the request to pre-approve admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with an L1 vertebral compression fracture. On 2/7/20, the enrollee ambulated 50 feet with minimal assistance. She participated in training exercises. On 2/10/20, her pain was 4/10. The enrollee ambulated 75 feet with minimal assistance. On 2/12/20, the enrollee was feeling better, with 3/10 pain. She ambulated 100 feet with contact guard assistance. She was progressing very well.The records do not support that the enrollee needs daily physical therapy (PT) and occupational therapy (OT). There are no noted daily skilled complex nursing needs. While she may well benefit from continuing PT and OT, the records do not support the need for daily therapy 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 admission toa skilled nursing facility (SNF) have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Absolute Quantitation of Myocardial Blood Flow (0428T) with Positron Emission Tomography (PET) provided on July 31, 2019.
You asked the Plan to pay for the Absolute Quantitation of Myocardial Blood Flow with PET imaging. You say that the services were medically necessary. The Plan denied your request. The Plan says the service at issue is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that Absolute Quantitation of Myocardial Blood Flow is not a covered service. We looked at the file and Medicare rules. The service at issue is not a covered service according to Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Absolute Quantitation of Myocardial Blood Flow with PET imaging have not been met. Therefore, we decided that the Plan does not have to pay for Absolute Quantitation of Myocardial Blood Flow (0428T) with Positron Emission Tomography (PET) provided on July 31, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the
enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says the Health Plan has no contractual obligation to cover services that are not
medically necessary or that do not meet Medicare criteria for coverage.
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 admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the records do not support that the
enrollee needs daily PT and OT. There are no noted daily skilled complex nursing needs. While she may
benefit from continuing PT and OT, the records do not support the need for daily therapy.
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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tumor Treatment Field Therapy (TTFT).
You asked the Plan to pre-approve Tumor Treatment Field Therapy. The Plan denied your request. The Plan says the coverage criteria are not met.
The Plan follows Medicare rules. Medicare rules say that TTFT is covered when all of the above 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 Tumor Treatment Field Therapy. Our reviewer says that the requested TTFT is not medically reasonable and necessary in this case. Our physician reviewer found that the documentation does not support that all of the coverage criteria for TTFT have been met in this case, as it is not documented that there is no evidence of progression by Response Assessment in Neuro-Oncology (RANO) criteria, or that the enrollee will use TTFT for an average of 18 hours per day. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Tumor Treatment Field Therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve Tumor Treatment Field Therapy (TTFT).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient mental health care from July 20, 2019 through July 25, 2019 provided by a non-participating facility.You asked the Plan to waive the copayment for inpatient mental health care. You say that you went to your doctor to get your medicine and the provider informed you that you needed to go to the emergency room and be put on a 72-hour hold in order to receive them.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits. The Plan states had the services been rendered at a regular hospital setting, you would have had a $0 copayment for these services.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 inpatient mental health care from July 20, 2019 through July 25, 2019. You are asked to pay a $900 copayment per admission for each inpatient stay at an in-network inpatient psychiatric facility. 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 mental health care from July 20, 2019 through July 25, 2019 provided by a non-participating facility.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that the ambulance was called because you were throwing up and close to passing out. You say that you were asked if you wanted to go to the hospital or be treated by the responders. You decided to receive treatment from the responders and not go to the hospital. You believe the Plan should cover the services because the cost would have been more if you had been transported.The Plan denied your request. The Plan says these services are not a covered benefit.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 May 6, 2019. 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 forthe ambulance services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve DBM allograft for the enrollee.
You asked the Plan to pre-approve DBM allograft. You say that DBM allograft is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 DBM allograft. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found DBM allograft is experimental when used alone for neck fusion. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of DBM allograft have not been met. Therefore, we decided that the Plan does not have to pre-approve DBM allograft for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 29, 2019 to August 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient hospital services. You say that you called the Plan on August 28, 2019 to obtain prior authorization. You say that you were advised that no authorization was required. You say that the services were quoted for in network providers only. You also say that the services were provided to the enrollee in good faith. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says the services could have been provided in network.
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 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 for the medical services provided on August 29, 2019 to August 30, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 18, 2019 to December 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you didn't know the provider was out-of-network. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 for the medical services provided on October 18, 2019 to December 23, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says the services were not urgent or emergent.
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 provider in this case is not a network provider with the Plan. The referring provider is not a network provider either. 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 for the medical services provided on August 26, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Otezla 30mg tablets.
You asked the Plan to pre-approve the Otezla tablets. You say that the enrollee needs this medication. The Plan denied your request. The Plan says the oral drug is not covered by Medicare 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 Otezla 30mg tablets.
Benefits for the Otezla 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee is medically stable, and does not require frequent medical provider evaluations.
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 physician reviewer found that the enrollee is at moderate assist for walking and grooming, and at maximum assist for lower body dressing and toileting. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 forthe resin based composites (D2392 x 3), the core build up (D2950 x 2), the crown (D2740 x 2), the periodontal scaling and root planing (D4341 x 2), and the inhalation of nitrous oxide (D9230) provided on September 28, 2019.You asked the Plan to pay forthe dental services. You say that the provider requested authorization for the services. You say that you thought the services would be covered because your provider advised the services were approved. You also say that you cannot afford to pay the balance.The Plan denied your request. The Plan says the annual maximum has been exceeded.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 annual maximum of $2,500 has been exceeded.Date of ServiceBilled AmountAllowed AmountPlan Paid8/2/2019$239$107$1078/5/2019$1,124$488$4888/12/2019$1,078$470$4708/22/2019$1,151$487$4879/28/2019$4,634$2,115$948TOTAL:$2,500Therefore, we decided that the Plan does not have to pay forthe resin based composites (D2392 x 3), the core build up (D2950 x 2), the crown (D2740 x 2), the periodontal scaling and root planing (D4341 x 2), and the inhalation of nitrous oxide (D9230) provided on September 28, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemical cauterization provided on August 28, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the wound care. You say that the service was provided to the enrollee at the request of the Medical Director. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the services could have been provided in network. The Plan also says that the services were not urgent or emergent in nature.
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 provider in this case is not a network provider with the Plan. The referring provider is not a network provider. The rendering facility is not a network provider either. 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 for the chemical cauterization provided on August 28, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approveOpdivo for the enrollee.You asked the Plan to pre-approveOpdivo. You say that Opdivo is medically necessary.The Plan denied your request. The Plan says that Medicare coverage criteria are not met.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 Opdivo. Our reviewer says that Medicare coverage criteria are met. Our physician reviewer found Opdivo is FDA approved for the treatment of metastatic non-small cell lung cancer (NSCLC) that has progressed on or after platinum-based chemotherapy. Patients with EGFR or ALK genomic tumor aberrations should have disease progression (on approved EGFR-or ALK-directed therapy) prior toreceiving nivolumab. This enrollee has received first line platin therapy and is EGFR and ALK negative. The service is reasonable and 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 Opdivo have been met.Therefore, we decided that the Plan has to pre-approveOpdivo for the enrollee.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.