Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered on March 21, 2019.
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 claim was not billed correctly.
The Plan must follow Medicare rules. The rules state that if the claim is for an episode in which there are no
skilled HH visits in billing period, but a policy exception that allows billing for covered services is documented
at the HHA, the HHA enters condition code 54.
We looked at the file and Medicare rules. The services at issue were home health aide services without skilled
visits and the claim was not billed with the required condition code 54. 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 home health services rendered on March 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) and core build up (D2950) for tooth #14. You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says that the crown is not medically necessary. The Plan also says that core build up is not a covered service. 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 the dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says that the crown for tooth #14 is not medically necessary. Our physician reviewer found the provided documentation does not show extensive missing or fractured structure of the tooth. Therefore, the reviewer found that there is no apparent need for a crown. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown has not been met. Additionally, core build up is not a covered service. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) and core build up (D2950) for tooth #14.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy services.
You asked the Plan to pre-approve the proton beam therapy services. You say that proton therapy is considered
a superior treatment option compared to x-ray treatment options. You say that, compared to IMRT, protons
deliver less than half of the radiation dose to surrounding normal tissues. You say that this excess radiation
does not benefit the enrollee in any way and increased the rate of toxicity. The Plan denied your request. The
Plan says the type of treatment requested is not known to be more effective than other types of radiation
therapy for the enrollee's cancer. The Plan says that Intensity-Modulated Radiation Therapy would be more
appropriate and approved if requested.
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 proton beam therapy services. Our
reviewer says that proton beam therapy services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the role of proton beam therapy versus external beam radiation therapy is
still being studied. Accepted medical guidelines, including the NCCN radiation compendium, recommend the
use of external beam radiation 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 proton beam therapy services have not been met. Therefore, we decided that
the Plan does not have to pre-approve proton beam therapy services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xifaxan 550mg tablet.
You asked the Plan to pre-approve Xifaxan 550mg tablet. You say that the requested medication is necessary.
The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part
D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Xifaxan 550mg tablet.
Benefits for Xifaxan 550mg tablet 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on
November 11, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that the transport was
medically necessary. The Plan denied your request. The Plan says that cost-sharing is a contractual obligation
and cannot be waived.
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 $200
copayment for each one-way Medicare-covered ground trip.
You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls
within the one-way Medicare-covered ground trip 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 for the ambulance transport provided on November 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit provided on January 20, 2020.
You asked the Plan to waive the copayment for the specialist visit. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a specialist visit on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $50 copayment for each specialist visit for Medicare-covered services. We looked at the file, the Plan's contract and Medicare rules. The file shows you received a specialist visit on January 20, 2020. You have been asked to pay a $50 copayment for the specialist visit. The specialist visit falls within the Physician/Practitioner services 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 for the specialist visit provided on January 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tecentriq and Alimta provided on November 26, 2019.
You asked the Plan to pay for the Tecentriq and Alimta provided on November 26, 2019. You say that the Tecentriq and Alimta provided on November 26, 2019 was medically necessary. The Plan denied your request. The Plan says the Tecentriq and Alimta provided on November 26, 2019 was 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 pay for the Tecentriq and Alimta provided on November 26, 2019. Our reviewer says that the Tecentriq and Alimta provided on November 26, 2019 was not medically necessary. Our physician reviewer found this review relates to a request to retrospectively cover Tecentriq and Alimta to be given in combination to treat a male with metastatic urothelial cancer of the renal pelvis. The NCCN Guidelines Version 5.2020 Upper GU Tract Tumors page UTT-1 refers to bladder cancer systemic treatments. Alimta is not FDA approved to treat bladder or urothelial cancers. Per the FDA website, Tecentriq is indicated for the treatment of adult patients with local advanced or metastatic urothelial carcinoma who have disease progression during or following any platinum-containing chemotherapy, or within 12 months of neoadjuvant or adjuvant chemotherapy. The label does not specify monotherapy or combination therapy. Alimta is category IIb indication for bladder cancer, which is a type of urothelial cancer. Clinical Pharmacology also supports it for second line treatment of transitional-cell bladder cancer without comment about single agent or combination use. However, the submitted article from the Journal of Clinical Oncology relates to the use of Alimta as a single agent. There were no citations for the use of the requested combination in a PubMed search. The NCCN compendium
only supports the use of Tecentriq as a single agent in the setting of metastatic bladder cancer. The NCCN Guidelines Version 5.2020 Bladder Cancer page updates indicates that Pemetrexed (Alimta) was removed from the list of regimens on page BL-G 3 of 7, principles of systemic therapy. Therefore, the requested combination is not supported by the NCCN compendium or the NCCN Guidelines. 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 Tecentriq and Alimta provided on November 26, 2019 have not been met. Therefore, we decided that the Plan does not have to pay for the Tecentriq and Alimta provided on November 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says your overall therapy needs do not require the intensity of an inpatient rehab.
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 you are neurologically stable and non-toxic. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You are at contact guard assist for functional transfers and gait. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an out of network (OON)
provider.
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services 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 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
office visits to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided on August 9, 2019 to
September 3, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the inpatient hospital services. You say that the services provided were medically
appropriate and necessary at the level of care provided. The Plan denied your request. The Plan says nonemergent
services with non-contracted providers require prior-authorization prior to services being rendered.
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 at issue in this case is not a network provider with the Plan. 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 hospital services. Our reviewer says that the requested
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer
found based on the documentation provided, the enrollee was stable for transfer to an in-plan facility at the time
of admission, following the ED evaluation. Any care provided after this time is post-stabilization care and
therefore not covered unless pre-authorized.
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 hospital services have not been met.
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 pay for the inpatient hospital services.
Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided on August
9, 2019 to September 3, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Computed Tomography (CT) of the abdomen and pelvis (74176) provided January 7, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment 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 Advanced Imaging Services. You have been asked to pay a $106.01 copayment for the CT scan. The allowable amount is less than the amount stipulated in the plan contract. The CT scan falls within the Advanced Imaging Services 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 for Computed Tomography (CT) of the abdomen and pelvis (74176) provided January 7, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the services provided on November 22, 2019 and November 23, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the medical criteria are not met.
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 does not provide a rationale for its denial. The plan has not referred to a Medicare rule to support its denial. The documentation submitted does not substantiate the plan's denial in this case. Therefore, we decided that the Plan has to pay for the services provided on November 22, 2019 and November 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an office visit (99203), orthopantagram (70355) and oral appliance (E0486NU) provided from November 19, 2019 through December 10, 2019 by an out-of-network provider.
You asked the Plan to waive the coinsurance for the services. You say that you are appealing your cost-share responsibility for the services you 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 show that you received an office visit (99203) and orthopantagram (70355) on November 19, 2019 and an oral appliance (E0486NU) on December 10, 2019 from an out-of-network provider. You are
asked to pay 30% coinsurance for out-of-network office services, 30% coinsurance for the x-rays and 30% coinsurance for the oral appliance. Your EOC states, 30% for out-of-network Medicare-covered DME and supplies, 30% coinsurance for each out-of-network Medicare-covered visit with a PCP or specialist and 30% coinsurance per day, per provider, for out-of-network Medicare-covered x-ray services. 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 an office visit (99203), orthopantagram (70355) and oral appliance (E0486NU) provided from November 19, 2019 through December 10, 2019 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device and accessories to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that the requested equipment can be provided by an in-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 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 mobility device and accessories to be provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says the
information provided did not support medical necessity.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 home health services. Our physician
reviewer found that the limited submitted medical records do not show that skilled nursing services s are
required to effectively provide services in order to improve the enrollee's condition, or to prevent deterioration.
There is no evidence of complex wound care, new enteral feeds, or other skilled nursing need. The limited
records do not show that skilled therapy services are required to effectively provide services in order to
improve the enrollee's level of function, or to establish a maintenance program to maintain the enrollee's level
of function, or prevent deterioration. There is no evidence of a physical therapy evaluation with the enrollee's
current functional abilities or need for skilled therapies. The documentation does not clearly reveal why the
enrollee is considered homebound. Without the need for skilled therapy and skilled services or clear indication
of being homebound, the services do not meet the definition of home health services. Therefore, the requested
services are 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 home health services have not been met. Therefore, we decided that the Plan
does not have to pre-approve home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical consultation.
You asked the Plan to pre-approve a surgical consultation. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a surgical consultation. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee has low back pain and symptoms of right sided lower extremity
radiculopathy. Magnetic resonance imaging shows degenerative changes with L5-S1 foraminal stenosis. The
documentation supports acute worsening of chronic back pain/right lower extremity radiculopathy with no red
flag symptoms and no acute findings on imaging, therefore, the enrollee does not meet criteria for the requested
surgical consultation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a surgical consultation have not been met. Therefore, we decided that the Plan
does not have to pre-approve a surgical consultation.