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

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail an injectable bisphosphonate first.
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. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the review indicates that the enrollee is with a history of osteoporosis. She tried oral bisphosphonate therapy with Alendronate but had significant GI issues. The Plan requires a trial of an injectable bisphosphonate first before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug. There is no documentation provided indicating that the Plan's required drug 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pneumatic compression device (E0651) and a segmental pneumatic appliance (E0667) provided on September 11, 2020.You asked the Plan to pre-approvethe pneumatic compression device and the segmental pneumatic appliance. You say that the items in dispute were medically necessary.The Plan denied your request. The Plan says the physical exam documents left lower extremity swelling, but no ulcers. The Plan says that the guidelines for coverage of the items in dispute have not been met.The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices are covered when certain coverage criteria have been met. Medicare rules also say that pneumatic compression device related accessories are only eligible for reimbursement when the appropriate relatedbased pneumatic compression device is eligible for reimbursement. 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 pneumatic compression device and the segmental pneumatic appliance. Our reviewer says that the criteria for coverage have not been met.Our physician reviewer found that the medical documentation provided does notshow that the pneumatic devices were provided for the treatment of lymphedema or for the treatment of chronic venous insufficiency with venous stasis ulcers. Our physician reviewer found that, while the documentation provided does show lower extremity swelling, they do not demonstrate that the enrollee has ulcers. 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pneumatic compression device and the segmental pneumatic appliance have not been met.Therefore, we decided that the Plan does not have to pre-approvea pneumatic compression device (E0651) and a segmental pneumatic appliance (E0667) provided on September 11, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for ultrasounds provided on August 26, 2020.
You asked the Plan to waive the deductible for ultrasounds. You say that you disagree with the charges and feel
that there was a billing error. 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. Your
contract with the Plan says that there is a $198 deductible for outpatient diagnostic tests and therapeutic
services and supplies.
You received ultrasounds on August 26, 2020. The record shows that you had paid $0 toward the $198
deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of
$156.32.
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is a $198 deductible for outpatient diagnostic tests and therapeutic services
and supplies. This cost sharing is a contractual obligation that had not been met at the time ultrasounds were
received on August 26, 2020. Therefore, we decided that the Plan does not have to waive the deductible for
ultrasounds provided on August 26, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentfor an ambulance transport (A0426) provided on August 11, 2020.You asked the Plan to waive the copaymentfor an ambulance transport. You say that you should not be responsible for paying the copay for the ambulance transport.The Plan denied your request. The Plan says the correct copay 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 an ambulance transport. You have been asked to pay a $150 copayment for ambulance transport. The services at issue fall within the ambulance 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 copaymentfor an ambulance transport (A0426) provided on August 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve supplemental benefits for the chronically ill. You asked the Plan to pre-approve supplemental benefits for the chronically ill. You say that the services are medically necessary. The Plan denied your request. The Plan says you do not have any eligible chronic conditions required for supplemental benefits. The Plan must follow Medicare rules. Medicare rules say that you may receive supplemental benefits for the chronically ill when you have an eligible chronic condition. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the supplemental benefits for the chronically ill have not been met. Specifically, the medical records submitted do not show that you have a chronic condition listed in the Plan's EOC that would qualify you for this supplemental benefit. Therefore, we decided that the Plan does not have to pre-approve supplemental benefits for the chronically ill.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on April 28, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network services are not covered.
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 you by an out-of-network provider on April 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation, full mouth
debridement, and consultation provided from July 20, 2020, to August 31, 2020.
You asked the Plan to pay for the cone beam CT capture and interpretation, full mouth debridement, and
consultation. You say that a Plan representative told you that these services would be covered. You also say
that you feel these services should be covered under your medical benefit. The Plan denied your request. The
Plan says these services are 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. The record shows that you contacted the Plan on July 21, 2020, and
accurate information was provided prior to the dental treatment being rendered. Therefore, we decided that the
Plan does not have to pay for the cone beam CT capture and interpretation, full mouth debridement, and
consultation provided from July 20, 2020, to August 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2391) provided on September
16, 2020.
You asked the Plan to pay for the resin-based composite. You say that you would like to be reimbursed for this
service because it was necessary. The Plan denied your request. The Plan says this service is not a covered
benefit under your dental plan.
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 resinbased
composite (D2391) provided on September 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora Medicare Part B drug provided on August 4, 2020.You asked the Plan to waive the coinsurance fora Medicare Part B drug. You say that you were not awareof the coinsurance charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on August 4, 2020. The allowed amount is $125 and 20% of that is $25. You have been asked to pay the total coinsurance amount of $25 for a Medicare Part B drug. A Medicare Part B drug falls within theMedicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance fora Medicare Part B drug provided on August 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional ten (10) physical therapy visits.
You asked the Plan to pre-approve an additional ten (10) physical therapy visits. The Plan denied your request.
The Plan says the additional ten (10) physical therapy visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 additional ten (10) physical therapy
visits. Our reviewer says that skilled services are not medically necessary to restore or maintain function or to
prevent deterioration of the enrollee's condition. Our physician reviewer found based on the medical records
provided there is no documentation that the requested therapy is generally accepted as specific and effective
therapy for the enrollee's condition. Based on the available records the enrollee's right hip appears to have
improved with therapy but she has obtained little benefit in the low back pain. Further formal therapy at this
point does not appear to be likely to achieve any significant improvement in the enrollee's symptoms or
functional status. Further utilization of the home exercise program appears appropriate at this point. Based on
the medical records provided there is no documentation that the unique skills of a professional therapist are
required to safely and effectively provide treatment, that the services can be safely and effectively performed
only by a therapist or under the supervision of a therapist. Based on the medical records provided there is no
documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to
establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow
further deterioration
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 additional ten (10) physical therapy visits have not been met. Therefore, we
decided that the Plan does not have to pre-approve an additional ten (10) physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, bitewings, first intraoral periapical x-ray, and three resin-based composites provided from August 18, 2020, to September 15, 2020.
You asked the Plan to pay for the comprehensive oral evaluation, bitewings, first intraoral periapical x-ray, and three resin-based composites. You say that at your first appointment, you were advised that you owed nothing for the services provided. You also say that you were told that you had a $250 allowance to use toward the fillings, and would only be charged $139.00 for each filling. The Plan denied your request. The Plan says you were correctly charged a $15 copayment for both the comprehensive oral evaluation and the bitewing x-rays. The Plan also says that your plan provides limited coverage for preventive dental services, and first intraoral periapical x-ray and resin-based composite are not covered benefits.
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, first intraoral periapical x-ray and resin-based composite are not among those covered under this benefit. The contract clearly states that you must pay a $15 copayment for each comprehensive oral exam, and a $15 copayment for bitewing x-rays. The record shows that you signed a financial agreement with the provider's office prior to the services being rendered. This agreement indicated that you would be responsible for the charges related to any non-covered services you received. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, bitewings, first intraoral periapical x-ray, and three resin-based composites provided from August 18, 2020, to September 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on March 27, 2020.You asked the Plan to pay forthe services. The Plandenied your request. The Plan says out-of-network services are not covered.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 servicesat 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 forthe medical services provided to youby an out-of-network provider on March 27, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you have broken ribs and difficulty breathing.The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the records document a need for physical therapy and occupational therapy, they do not document a need for an intensive rehabilitation program. There is not a reasonable expectation that you 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 Medicarerules. 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee will benefit from transfer to LTACH.The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.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. Our physician reviewer found as LTACHs and acute care hospitals are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current acute care hospital until such time as no acute services are required, then be transferred/discharged to alower level of care for any ongoing long-term care needs.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-approvelong term acute care hospital (LTACH) services
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for BRCA1 and BRCA2 genetic testing provided on April 20, 2020.
You asked the Plan to pay for the genetic testing. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says that this service has not been reported correctly.
The Plan follows Medicare rules. Medicare rules say that BRCA1 and BRCA2 genetic testing is considered medically necessary for a beneficiary with a current diagnosis or a personal history of a cancer associated with the BRCA mutation who meets one or more of the criteria found in the most recent version of the NCCN guidelines for Genetic/Familial High-Risk Assessment. 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 genetic testing. Our reviewer says that this member meets current NCCN Guidelines for genetic testing for BRCA1 and BRCA2 testing as well as panel genetic testing. This is based on a personal history of 3 or more breast cancers and a family history of prostate cancer in her father. Our physician reviewer found at the time of the patients' bilateral mastectomies she had bilateral lobular breast cancers and an additional ductal breast cancer on the right. 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 genetic testing have been met. Therefore, we decided that the Plan has to pay for BRCA1 and BRCA2 genetic testing provided on April 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost forthe luspatercept injection and laboratory tests provided on July 14, 2020 and August 25, 2020.You asked the Plan to waive the cost forthe luspatercept injection and laboratory tests. You say that you are appealing the drug charges.The Plan denied your request. The Plan says the cost share 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 clearlysays that you must pay 20% coinsurance for Part B injectable drugs that aren't self-administered from an in-network provider and a$10 copayment for lab services from an in-network provider.You have been asked to pay a total of $4,628.96 for the luspatercept injection and laboratory tests. The luspatercept injection falls within the "Medicare Part B prescription drugs" benefit category. The laboratory tests fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the cost forthe luspatercept injection and laboratory tests provided on July 14, 2020 and August 25, 2020.