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

We decided that the Plan does not have to pre-approveCamptosar (J9206) and Panitumumab (J9303).You asked the Plan to pre-approveCamptosar and Panitumumab. You say that this is medically necessary.The Plan denied your request. The Plan says these drugs are not supported for the enrollee's condition.The Plan must follow Medicare rules. Therules 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 relevantMedicare rules to determine if the Plan was correct in denying the request to pre-approve Camptosar and Panitumumab. Our reviewer says that the criteria for coverage of these drugs has not been met. Our physician reviewer found the use of Camptosar and Panitumumab is not FDA-approved for the enrollee's diagnosis. Acombination of panitumumab and irinotecan with gemcitabine is a standard regimen but not these two drugs alone. In a study looking at colon cacner patients the combination of panitumumab and irinotecan did not improve overall survival.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Camptosar and Panitumumab have not been met.Therefore, we decided that the Plan does not have to pre-approveCamptosar (J9206) and Panitumumab (J9303).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.You asked the Plan to pre-approve exceptions to supplemental benefits. You say that you require additional miles to get to medical appointments.The Plan denied your request. The Plan says that your request exceeds the mileage limit.Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits they are not required to do so. Medicare does not provide exceptions to supplemental benefits.Therefore, we decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOrthovisc.You asked the Plan to pre-approveOrthovisc. You say that Orthovisc is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for Orthovisc.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 Orthovisc. Our reviewer says that the enrollee does not meet criteria for Orthovisc. Our physician reviewer found enrollee has osteoarthritis of the Right knee. She had a steroid injection of the Rightknee in January '20. The request was made for viscosupplementation soon thereafter. There is no documentation of Physical therapy or other trials of conservative therapy which have been tried for 3 months. Therefore, the criteria of the LCD are not met and the request is considered 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 Orthovisc have not been met.Therefore, we decided that the Plan does not have to pre-approveOrthovisc.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 20, 2019 by an out of network (OON) provider.You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is out-of-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 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 lab work provided on December 20, 2019 by an out of network (OON) provider.
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 enrollee is willing, and will benefit from therapy that can only be offered in acute inpatient rehab.The Plan denied your request. The Plan says the enrollee is unable to participate in intensive therapy, and does not need an intensive team 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 enrollee is medically stable after a revision of a left total hip arthroplasty, with no recent neurological events. There is no evidence of complex medical issues that require monitoring by an inpatient rehab physician three times per week, or need for acute rehab nursing care. The enrollee is unable to participate due to fatigue and pain. He needs max assist for activities of daily living and mobility. While he may benefit from continuing physical and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care.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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Durolane.
You asked the Plan to pre-approve Durolane. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for Durolane is correct, because the Plan requires a trial of Orthovisc and Monovisc before it will approve Durolane.
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 Durolane. Our reviewer says that you do not meet the Medicare criteria for a step therapy exception for Durolane. Our physician reviewer found the documentation does not show that you have tried and failed the Plan's preferred drugs of Orthovisc and Monovisc. The documentation submitted does not show that the Plan's preferred drugs are likely to be less effective and/or have adverse effects for you.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Durolane.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear purchased on January 1, 2020 from an out-ofnetwork
provider.
You asked the Plan to pay for the eyewear. You say that you are appealing for reconsideration of the denied
charges. The Plan denied your request. The Plan says you do not have out-of-network benefits.
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. The
provider is not in-network and your EOC clearly states, you have a choice of $200 benefit toward the purchase
and fitting of eyeglasses and pair of lenses or contact lenses at a network optical provider (one (1) per calendar
year). Therefore, we decided that the Plan does not have to pay for the eyewear purchased on January 1, 2020
from an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Alvesco 80mcg inhaler.
You asked the Plan to pre-approve the Alvesco inhaler. You say that the enrollee needs this drug due to her asthma. The Plan denied your request. The Plan says this drug is self-administered and can only be covered by Part D.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Alvesco 80mcg inhaler.
Benefits for the Alvesco inhaler 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care services provided on December 19, 2019.
You asked the Plan to pay for the wound care services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 wound care services provided on December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit for wound care provided on December 24, 2019.

You asked the Plan to pay for the domiciliary, rest home visit for wound care. The Plan denied your request. The Plan says that the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 a domiciliary, rest home visit for wound care provided on December 24, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on February 4, 2020.You asked the Plan to waive the copayment for the endoscopy. You say that you have never had to pay this much for services before.The Plan denied your request. The Plan says the copayment 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 a $275 copayment for each Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility.You have been asked to pay a $275 copayment for the endoscopy. The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The endoscopy is considered a surgical procedure. 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 endoscopy provided on February 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the fibular fracture treatment provided on January 22, 2020.
You asked the Plan to waive the copayment for the fibular fracture treatment. You say that you should not be responsible for the outpatient surgery copayment because no surgery took place. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $200 copayment per visit for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. The enrollee has been asked to pay a $200 copayment for the fibular fracture treatment. The fibular fracture treatment falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the enrollee was billed for a fibular fracture treatment, which is considered a surgical procedure.
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the fibular fracture treatment provided on January 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lens, per lens (V2781) purchased on November
26, 2019 from an out-of-network provider.
You asked the Plan to pay for the progressive lens. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says this item is not covered under Medicare or the
Health Plan and the provider is not in-network with your 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.
This item is not covered under Medicare or the Health Plan and the provider is not in-network with your plan.
Therefore, we decided that the Plan does not have to pay for progressive lens, per lens (V2781) purchased on
November 26, 2019 from an out-of-network provider.
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 you do not need intensive therapy, or an intensive team for your 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 you are at minimal assist with a rolling walker and transfers. Your pain is controlled on oral analgesics. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical status does not require intensive physician or nursing oversight in an IRF. You may may benefit from additional multiple therapies, however your functional level does not require or indicate that this therapy must be in an IRF with an intensive level 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and bitewings provided on September 23, 2019, and the resin-based composite, and inhalation of nitrous oxide provided on October 3, 2019.
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, bitewings, resin-based composite, and inhalation of nitrous oxide. You say that you are having issues with dental services not being paid. You also say that you contacted the Plan and were notified that the dentist you saw was not on the list of contracted providers. The Plan denied your request. The Plan says the services you received on September 23, 2019 were rendered by an out-of-network provider. The Plan also says that they correctly paid their cost share of the resin-based composite. The Plan also says that the inhalation of nitrous oxide is not a covered benefit.
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 covered when they are received out-of-network. The contract says that resin-based composites provided on a posterior tooth will be partially covered with an amalgam allowance and you are responsible for the difference in the cost. The record shows that the Plan partially paid for your resin-based composite, and you must pay the remaining balance. The contract also says that general anesthesia or intravenous sedation is covered when provided in conjunction with covered endodontic, periodontic, or oral surgery dental care. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and bitewings provided on September 23, 2019, and the resin-based composite, and inhalation of nitrous oxide provided on October 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 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 reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you were admitted to the hospital on June 3, 2020 with left hip fracture and underwent surgical repair. You need assistance with walking 10 feet with a rolling walker. You have no complex medical, nursing, or rehabilitation needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical status does not require intensive physician or nursing oversight in an IRF. You may benefit from further therapy but do not require an intensive therapy program 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from January 14, 2020 through January 17, 2020.You asked the Plan to waive the copayment for the inpatient stay. You say that this should be rebilled to the proper code. You say that you are unable to pay this charge.The Plan denied your request. The Plan says the copayment 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 a $450 copayment per day, days 1 to 4 at an in-network inpatient hospital.You have been asked to pay a $1,350 copayment for the inpatient stay. ($450/day x 3 days = $1,350). The inpatient stay falls within the "Inpatient hospital care" benefit category. The records show that you were admitted as an inpatient for three days. 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 inpatient stay provided from January 14, 2020 through January 17, 2020.