Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that LTACHs do not provide clinical advantage over a non
LTACH acute care hospitals.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee
is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the
LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on July 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the nursing facility care. You say that you are contracted with the facility where the enrollee resides, and the facility failed to obtain prior authorization. The Plan denied your request. The Plan says they only cover out-of-network care in limited circumstances. The services provided were not urgent or pre-approved. It is the responsibility of the provider or facility to verify the enrollee's eligibility and obtain 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 had network providers available who could have provided 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 subsequent nursing facility care (99308) provided on July 24, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia.

You asked the Plan to pay for anesthesia for percutaneous image guided procedures on the spine and spinal cord; therapeutic (01936). You say that the Plan should pay this claim. The Plan denied your request. The Plan says there are no documented extenuating circumstances to support an exception to the policy.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. The medical records do not support rare unique circumstances of medical necessity for the anesthesia. Based on this information, we decided that Medicare rules for coverage of anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department visit for the evaluation and management of a patient (99283) provided January 11, 2019.
You asked the Plan to pay for the emergency department visit. You say that good cause exists for this timely filing denial. Prompt reconsideration of your claim for appropriate reimbursement due to good cause. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the emergency department visit was not filed until January 13, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for emergency department visit for the evaluation and management of a patient (99283) provided January 11, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60mg/ml syringe for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says a step therapy exception cannot be granted.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found there is no history of osteoporosis-related fracture. There is no evidence of a trial and failure of zoledronic acid. There is no evidence that zoledronic acid would likely be less effective and/or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia 60mg/ml syringe for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.

You asked the Plan to pre-approve the Retacrit. You say that the request for continued use of the requested
drug is not associated with Leukemia. You say that the enrollee is currently under chemotherapy treatment and
has chemotherapy induced anemia. You say that the treatment being requested is a continuation that is
medically necessary and indicated for the enrollee's prognosis. The Plan denied your request. The Plan says the
requested drug is not reasonable and necessary when the anemia is associated with the treatment of acute and
chronic myelogenous leukemias.

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 the Retacrit. Our reviewer says that the
criteria for coverage of Retacrit have not been met. Our physician reviewer found the use of Retacrit is not
FDA-approved for the enrollee's diagnosis. Treatment of anemia in patients with non-myeloid malignancies,
and in which anemia is due to the effect of concomitant myelosuppressive chemotherapy, require a minimum
of 2 additional months of planned chemotherapy. In addition, the enrollee's hemoglobin is 10, which is above
the criteria for starting the use of this drug. Our physician reviewer found that use of this drug in the enrollee's
case is not supported by one of the major drug compendia or by clinical research that appears in a CMSapproved
medical journal.

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 Retacrit have not been met. Therefore, we decided that the Plan does not
have to pre-approve Retacrit.
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. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical treatment of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit.

You asked the Plan to waive the copayment for a specialist visit. You say that you just received a COVID-19
test and did not see a provider. 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 $40
copayment for specialist services.

The medical records show that you had a specialist visit. Therefore, you are responsible to pay the allowed 
amount of $22.54, which is less than the $40 copayment.

You have been asked to pay the allowed amount of $22.54 for a specialist visit. A specialist visit falls within
the physician/practitioner services, including doctor's office visits 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 a specialist visit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care provided by an out-of-network provider.

You asked the Plan to pay for observation care. You say that you submitted documentation supporting payment
for the claim. The Plan denied your request. The Plan says this provider is not a network provider with 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 had network providers
available who could have provided 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 observation care provided by an out-of-network
provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a stress test provided by a participating
provider.

You asked the Plan to waive the copayment for a stress test. You say that you were never told that you would
have a copayment. The Plan denied your request. The Plan says the correct copayment has been 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 $100
copayment for outpatient diagnostic tests/nuclear medicine.

You have been asked to pay a $100 copayment for a stress test. A stress test falls within the outpatient
diagnostic tests/nuclear medicine 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 a
stress test provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medial branch blocks.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the
enrollee has low back pain that moves to the legs.

The Plan follows Medicare rules. Medicare rules say that facet joint injections are only covered under certain
medical indications.

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 requested services. Our physician
reviewer found that the enrollee has chronic low back pain which radiates into both legs into her feet. She has
documented sensory and reflex changes. She is taking Norco and Naproxen for pain. The request is for medial
branch blocks. The progress notes clearly document radicular pain, sensory and reflex changes in both legs.
This does not meet the coverage criteria. Therefore, the request is deemed 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 the requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve medial branch blocks.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the gingival irrigation (D4921).

You asked the Plan to reimburse you for the gingival irrigation. You say that you had a lot of x-rays done. You say that you were given an estimate that was very shocking. You say that you only had your teeth cleaned that day. You also say that you were charged $399. The Plan denied your request. The Plan says gingival irrigation is not listed as a covered service. The Plan says that the $399 total includes the member responsibility for the services that you received.

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 gingival irrigation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the gingival irrigation (D4921).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on November 16, 2020.
You asked the Plan to pay for the dental service. You say that you have dental work that needs to be done. You say that you are not financially able to pay a copayment or a bill. You say that you are on a limited, fixed income. You also say that this is a very stressful situation when you do not have money to pay a bill that is due. The Plan denied your request. The Plan says comprehensive periodontal evaluation is not listed as 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on November 16, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for physician services provided to the enrollee and billed under code 99358.

You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says that their time to review this claim expired and no determination was made.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 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 this service. Our reviewers says that Medicare billing criteria are met. Our physician reviewer found Current Procedural Terminology (CPT) code 99358 is defined as Prolonged evaluation and management service before and/or after direct patient care; first hour. The medical records submitted verifies that 99358 was used to report Prolonged evaluation and management service before and/or after direct patient care; first hour and 99358 was not reported in association with a companion E/M code that also qualifies as the initiating visit for CCM services, therefore this code should be paid. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have been met. Therefore, we decided that the Plan has to pay for physician services provided to the enrollee and billed under code 99358.

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 5, 2020.
You asked the Plan to pay for the ambulance services. You say that this charge should be adjusted. 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 September 5, 2020. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 5,
2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery has not been demonstrated in the peer-reviewed literature.

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 services are not considered medically reasonable and necessary in this case. Bone marrow aspirate remains experimental. More research is needed to show safety and efficacy. Iliac crest bone graft is the gold standard. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 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 does not have to pre-approve bone marrow aspirate for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Levofloxacin, 750 mg tablet provided in an outpatient setting on November 25, 2020.
You asked the Plan to pay for the self-administered drug. You say that you were advised to send this to your prescription carrier for reimbursement. The Plan denied your request. The Plan says the drug you received is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drug you received is not covered under 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 pay for Levofloxacin, 750 mg tablet provided in an outpatient setting on November 25, 2020.
Benefits for the self-administered drug 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on November 16, 2020.
You asked the Plan to waive the copayment for EKG. You say that there was no charge for this service in the previous year. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 copayment for EKG provided by a PCP. You have been asked to pay the allowed amount of $14.93, which is less than the $15 copayment for EKG. EKG falls 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 for an electrocardiogram (EKG) provided on November 16, 2020.