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

We decided that the Plan does not have to pre-approve Prevention Genetics Targeted HNF4A Gene Testing for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is medically necessary to help the enrollee's medical management. The Plan denied your request. The Plan says this is not covered for risk assessment of family members, when it is not needed to make treatment decisions for the enrollee.
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 testing. Our reviewer says that the requested testing is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have diabetes, possibly due to a genetic variant. There is no evidence to support that the requested test, to confirm the genetic variant, will affect the fact that the enrollee has diabetes or that she requires diabetes treatment. The requested test is not medically necessary or reasonable to diagnose, treat or otherwise manage the enrollee's condition(s). 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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Prevention Genetics Targeted HNF4A Gene Testing for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the aflibercept injection provided on January 7, 2020, February 4, 2020 and March 3, 2020.You asked the Plan to waive the coinsurance for the aflibercept injection. You say that you don't have any extra money to pay.The Plan denied your request. The Plan says the coinsurance applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 15% of the total cost for Medicare-covered Part B prescription drugs, including chemotherapy drugs.You have been asked to pay a total of $850.53 for the aflibercept injections. Date of Service Service Allowed Amount Coinsurance Member Liability January 7, 2020Aflibercept Injection$1,890.0615%$283.51February 4, 2020Aflibercept Injection$1,890.0615%$283.51March 3, 2020Aflibercept Injection$1,890.0615%$283.51TOTAL:$850.53 The aflibercept injections fall within the "Medicare Part B prescription drugs" 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 coinsurance for the aflibercept injection provided on January 7, 2020, February 4, 2020 and March 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided onNovember 14, 2019 to November 25, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe surgery services. You say that you would like reconsideration because the office was misinformed regarding the member's benefits.The Plan denied your request. The Plan says this provider is out-of-network and did not request prior authorization prior to rendering services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plansays 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 forthe medical services provided on November 14, 2019 to November 25, 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 extraspinal chiropractic manipulation (98943) provided from December 30, 2019 to January 3, 2020.
You asked the Plan to pay for extraspinal chiropractic manipulation. You say that this service improves the condition of your life. The Plan denied your request. The Plan says this service is not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for extraspinal chiropractic manipulation (98943) provided from December 30, 2019 to January 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetransfer to another acute inpatient hospital for the enrollee.You asked the Plan to pre-approvethese services. The Plan denied your request. The Plan says that the member is receiving standard of care.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 requested service is not considered medically reasonable and necessary in this case. The medical record demonstrates that the enrollee's care is adequately and safely being managed at current acute care facility. The medical records do not show evidence that the current acute care hospital cannot safely treat the enrollee's condition. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met.Therefore, we decided that the Plan doesnot have to pre-approvetransfer to another acute inpatient hospital for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.You asked the Plan to pre-approve the compression stockings. You say that the tighter compression stockings were too tight and that these are required to prevent blood clots in your legs.The Plan denied your request. The Plan says these stockings are examples of wound care items which are non-covered under the surgical dressing benefit because they do not meet the statutory definition of a dressing.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services that you provided on December 17, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says services from non-participating providers are not covered unless they are authorized by 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 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 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 for physician's services that you provided on December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 26, 2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says services from non-participating providers are not covered under the Plan unless they are authorized by the Plan before the services are provided.
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 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 for subsequent nursing facility care provided on June 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory services provided on February 5, 2020.You asked the Plan to waive the copayment forlaboratory services. You say that you disagree with the charges because you have never had to pay in the past.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 $10 copayment for laboratory tests. You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall 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 forlaboratory services provided on February 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on January 16, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 pay for the drug testing rendered on January 16, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient mental health care provided on February 13, 2020 and February 27, 2020.You asked the Plan to waive the copayments for outpatient mental health care. You say that you cannot afford 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 $35 copayment for outpatient mental health care. You received outpatient mental health care on February 13, 2020 and February 27, 2020. Therefore, you are responsible to pay a $35 copayment per each visit. The total amount you owe is: $70. You have been asked to pay the total copayment amount of $70for outpatient mental health care. Outpatient mental health care falls within the outpatient mental health care 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 copayments for outpatient mental health care provided on February 13, 2020 and February 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for gym membership fees purchased February 1, 2020. You asked the Plan to pay for the gym membership fees. You say that you are currently in Florida and will be there until early May and wanted to stay healthy while there so you joined a gym. You feel that you should be reimbursed for the costs. The Plan denied your request. The Plan says this provider is not a participating fitness location. 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 covers gym benefits only when obtained from a participating fitness location. The Plan's rules for coverage of gym benefits have not been met because the gym is not is not a participating fitness location. Therefore, we decided that the Plan does not have to pay for gym membership fees purchased February 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for renal dialysis provided from January 4, 2020 to January 28, 2020.
You asked the Plan to waive the coinsurance for renal dialysis. You say that you cannot afford 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 20% coinsurance for services to treat kidney disease. You received renal dialysis from January 4, 2020 to January 28, 2020 for a total of 8 services. The allowed amount per each service is $327.60 and 20% of that is $65.52. The total amount you owe is: $65.52 (coinsurance) x 8 (services) = $524.16. You have been asked to pay the total coinsurance amount of $524.16 for renal dialysis. Renal dialysis falls within the services to treat kidney disease 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 coinsurance for renal dialysis provided from January 4, 2020 to January 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health services.
You asked the Plan to pre-approve inpatient mental health services. You say that inpatient mental health care is medically necessary. The Plan denied your request. The Plan says rules for coverage were not met.
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 pre-approve inpatient mental health services. Our reviewer says that inpatient level care is not medically necessary. Our physician reviewer found based upon review the records provided for the admission of this enrollee does not meet criteria for acute inpatient mental health treatment as she was not shown to be a danger to herself or others, had no auditory or visual hallucinations, and was noted to be cooperative and compliant with treatment while not showing any aggressive behaviors. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.
You asked the Plan to pre-approve Retacrit. 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 medically necessary.
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 Retacrit. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee is being treated with adjuvant chemotherapy for stage III rectal cancer. The enrollee was started on iron therapy for low iron on June 2, 2020. The documentation does not adequately meet the FDA indication. Retacrit is indicated for the treatment of anemia in enrollees with non-myeloid malignancies where anemia is due to the effect of concomitant myelosuppressive chemotherapy, and upon initiation, there is a minimum of two additional months of planned chemotherapy. The enrollee's anemia has multiple etiologies for the cancer in addition to chemotherapy. These include cirrhosis, moderated CKD and blood loss. In addition, the submitted documents do not indicate that there are at least two (2) additional months of planned chemotherapy. The NCCN compendium states erythropoiesis-stimulating agents are not recommended when myelosuppressive chemotherapy is given with curative intent, for enrollees with cancer who are not receiving therapy, or for enrollees receiving non-myelosuppressive therapy. Adjuvant therapy is part of curative treatment. The records indicate that the treatment is adjuvant and there is no other statement regarding the goals of treatment. Also, it is unknown what effect the iron treatment will have on the enrollee's anemia. Therefore, the enrollee does not meet criteria for the requested drug. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered from January 22, 2020 to February 5,
2020.
You asked the Plan to pay for these services. You say that the services were for an emergency while on
vacation. The Plan denied your request. The Plan says the services were rendered by an out-of-area provider
without prior authorization.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and
pre-approved care.
We looked at the file and Medicare rules. The file shows that the enrollee received services outside of the Plan
service area with a known need for care prior to travel. The services were not for an unforeseen illness or
injury. 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 pay for the services rendered from January 22, 2020
to February 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. 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 December 19, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
You asked the Plan to pre-approve radiofrequency ablation (RFA). You say that the requested RFA is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested RFA.
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 radiofrequency ablation (RFA). Our reviewer says that the enrollee does not meet criteria for the requested RFA. Our physician reviewer found the enrollee has chronic low back pain. The enrollee has had medication trials. She has had 2 epidural steroid injections. She had only one set of diagnostic Left Lumbar Medial Branch Blocks L3-S1 which gave her 80% pain relief. She has not had a second set of diagnostic blocks as required. She has not had Right sided diagnostic blocks. There is no documentation of a second set of Left MBB L3-S1 diagnostic blocks. There is no 1st or 2nd set of diagnostic MBBs on the Right side. The request does not meet the criteria of the LCD. The request is 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 radiofrequency ablation (RFA) have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forface down recovery equipment (E1399) provided December 20, 2019.You asked the Plan to pay forthe face down recovery equipment. You say that you rented the face down recovery equipment in order to facilitate your recovery following Macular Hole surgery and you feel that this item should be covered.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pay forface down recovery equipment (E1399) provided December 20, 2019.