Persius/hicric huggingface dataset:
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 home health is not taking care of you. The Plan denied your request. The Plan says you do not need to take part in 3 hours of therapy a day, or an intensive team approach for care.
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 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 minimal to standby assist for functional transfers and activities of daily living. 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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve 450mg Carboplatin.
You asked the Plan to pre-approve the Carboplatin. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says that the off-label use of this drug is not
accepted.
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 Carboplatin. Our reviewer says that
the member with a stage IIIB non-small cell lung cancer will receive weekly carboplatin with paclitaxel in
combination with radiation. This is a standard regimen for the treatment of non-small cell lung cancer and an
appropriate use of carboplatin. Our physician reviewer found 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 the Carboplatin have been met. Therefore, we decided that the Plan has to preapprove
450mg Carboplatin.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 11, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on August 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care (99307) provided on August 27, 2018.
You asked the Plan to pay for nursing facility care. You say that this was filed timely. The Plan denied your request. The Plan says this claim was received more than a year after the date of service.
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 nursing facility care was not filed until November 1, 2019. 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 nursing facility care (99307) provided on August 27, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 18, 2019 by an out of network (OON) provider.You asked the Plan to pay for the radiology services (72050, 72070 and 72100). You say that you would like reconsideration as these services were medically necessary. The Plan denied your request. The Plan says utilization of network providers and authorization for certain services is necessary.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 November 18, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forprimary care provider visits and a specialist visit provided by out-of-network providers from August 8, 2019 to August 22, 2019.You asked the Plan to waive the copayments forprimary care provider visits and a specialist visit. You say that you were not informed that the providers were out-of-network.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 $50 copayment for services obtained by an out-of-network primary care physician and a $75 copayment for services obtained from an out-of-network specialistYou had primary care provider visits from out-of-network providers on August 8, 2019 and August 16, 2019. Therefore, you are responsible to pay a $50 copayment per each visit. The total amount you owe is: $100. You had a specialist visit with an out-of-network provider on August 22, 2019. Therefore, you are responsible to pay the $75 copayment. The total amountyou owe is: $175. You have been asked to pay the total copayment amount of $175 for primary care provider visits and a specialist visit. Primary care provider visits and a specialist visit fall 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 copayments forprimary care provider visits and a specialist visit provided by out-of-network providers from August 8, 2019 to August 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Planhasto pre-approveCT scan of the chest for the enrollee.You asked the Planto pre-approvethe scan. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthere is a lack of medical necessity for this service.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 the scan. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found although the PET/CT was negative in October, 2019 small pulmonary nodules indicative of metastatic disease could have been inapparent as they could be too small to show increased metabolic activity. For this reason, CT of the chest is reasonable given the propensity of malignant melanoma to metastasize to lung.We looked at this physician's review, the file, and Medicare rules. Based on this information, wedecided that Medicare rules for coverage of the scan have been met.Therefore, we decided that the Planhas to pre-approveCT scan of the chest for the enrollee.If the Plandoes 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/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2 extractions (D7140) provided from August 28, 2019 to September 16, 2019 by the out of network provider.
You asked the Plan to pay for the dental services. You say that you would like assistance with this bill. You also say that you would like to be able to move forward with getting your dental work done. The Plan denied your request. The Plan says comprehensive dental services that you receive out of network have a 50% coinsurance. The Plan also says 1 extraction per year is covered.
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 and extractions are a covered service, the frequency limit has been exceeded. The record shows that the Plan previously paid for the extraction that you received on August 28, 2019. Additionally, there is a 50% coinsurance for dental services that you receive out of network. Therefore, we decided that the Plan does not have to pay for the 2 extractions (D7140) provided from August 28, 2019 to September 16, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that a prescription for the requested orthotics was sent. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eyeglasses (frames and lenses).
You asked the Plan to pre-approve the eyeglasses. You say that your provider told you in order to determine if surgery is needed you need to get the glasses first. The Plan denied your request. The Plan says this request exceeds the benefit limitation of once every 2 years.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $300 for eyeglasses (frames and lenses) or contact lenses every 2 years. The records show you obtained your current glasses August 16, 2018. The eyewear benefit will not be available until August 1, 2020.We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pre-approve eyeglasses (frames and lenses).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve an MRI of the breast, including computer-aided detection (77049).You asked the Plan to pre-approve an MRI of the breast, including computer-aided detection (77049). You say that the requested MRI is medically necessary.The Plan denied your request. The Plan says that the requested MRI is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of the breast, including computer-aided detection (77049). Our reviewer says that the requested MRI is medically necessary. Our physician reviewer found the review indicates that the enrollee had a routine mammogram but noted to have dense breast tissue. There is not enough evidence to make a recommendation for or against yearly MRI screening for women who have a moderately increased risk of breast cancer (a lifetime risk of 15-20% according to risk-assessment tools that are based mainly on family history) or who may be at increased risk of breast cancer based on certain factors, such as (1) having a personal history of breast cancer, ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS), atypicalductal hyperplasia (ADH), or atypical lobular hyperplasia (ALH) or (2) having dense breasts ("extremely" or "heterogeneously" dense) as seen on a mammogram.If MRI is used, it should be in addition to, not instead of, a screening mammogram. This is because although an MRI is a more sensitive test (it's more likely to detect cancer than a mammogram), it may still miss some cancers that a mammogram would detect. For most women at high risk, screening with MRI and mammograms should begin at age 30 years and continue for as long as a woman is in good health. The review indicates that the requested MRI is medically reasonable and necessary 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 an MRI of the breast, including computer-aided detection (77049) have been met.Therefore, we decided that the Plan has to pre-approvean MRI of the breast, including computer-aided detection (77049).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fornursing home care provided on July 18, 2019.You asked the Plan to pay forthe nursing home care. You say that this provider is the only wound specialist working for the nursing home where this patient is residing.The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 servicesat 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 fornursing home care providedon July 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit you had on October 29, 2019.You asked the Plan to pay for the annual wellness visit. The Plan denied your request. The Plan says you already had an annual wellness visit for 2019.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 $0 copayment for one annual wellness visit every 12 months. Review of the file shows that you had an annual wellness visit on October 29, 2019. The records also show that you had a covered annual wellness visit on February 11, 2019. The plan only covers one annual wellness visit every 12 months. This means that the requested visit exceeds the benefit limit and is not covered. This means that you have been asked to pay the correct amount based on your contract with the Plan.Therefore, we decided that the Plan does not have to pay for the annual wellness visit you had on October 29, 2019
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60mg/ml syringe (J0897).
You asked the Plan to pre-approve Prolia 60mg/ml syringe. You say that the requested medication is necessary.
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step
therapy exception has not been met.
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 Prolia 60mg/ml syringe. Our reviewer
says that the medication is not medically necessary. Our physician reviewer found the documentation does not
support that Zoledronic acid would likely be less effective, and/or would likely have adverse effects for the
enrollee 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 Prolia 60mg/ml syringe have not been met. Therefore, we decided that the Plan
does not have to pre-approve Prolia 60mg/ml syringe (J0897).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on November 5, 2019.You asked the Plan to pay for the dental service. You say that per the Evidence of Coverage, you are only responsible for the 20% coinsurance. You also say that this was a diagnostic service.The Plan denied your request. The Plan says oral exams are covered no more than twice per year. The Plan also says that the frequency limit 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 and periodic oral evaluations are a covered service, the frequency limit has been exceeded. The record shows that the Plan previously paid for oral exams that you received on February 27, 2019 and August 27, 2019.Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on November 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe prefabricated post and core in addition to crown (D2954) provided on May 30, 2019.You asked the Plan to pay forthe prefabricated post and core. You say that the crown could not be done without performing a prefabricated post and core (D2954). You also say that a pre-authorization request was completed but the enrollee was not informed that the procedure was not covered.The Plan denied your request. The Plan says this service is not covered.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 forthe prefabricated post and core in addition to crown (D2954) provided on May 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe consultation (D9310) provided on October 21, 2019.You asked the Plan to pay forthe dental service. You say that your regular dentist referred you to the endodontist for a possible root canal.The Plan denied your request. The Plan says the consultation 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 consultation you received is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe consultation (D9310) provided on October 21, 2019.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
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 SNF care. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee requires both daily skilled therapy and nursing services. The enrollee had previously been able to function using a walker. There is a reasonable expectation of improvement with a return to her prior level of function through the SNF level care being requested. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.new information. This does not happen often. If we decide to open the case again, we will se