Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordental services (D0140 and D1999) received on September 1, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthis 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 among those covered under this benefit.Therefore, we decided that the Plandoes not haveto pay fordental services (D0140 and D1999) received on September 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRituximab.You asked the Plan to pre-approveRituximab. You say that the drug is FDA-approved for neuromyelitis optica.The Plan denied your request. The Plan says the enrollee does not have a diagnosis that is indicated for coverage.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Rituximab. Our physician reviewer found that Rituximab is not FDA-approved for use in neuromyelitis optica (NMO). The use of Rituximab in NMO is not supported in the Medicare accepted Compendia, nor was any literature provided from CMS approved journals. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Rituximab have not been met.Therefore, we decided that the Plan does not have to pre-approveRituximab.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out-of-network provider.You asked the Plan to pre-approvethe medical services. You say that you are requesting review of denial of services.The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider and the services were not urgent or emergent, nor were they approved in advance.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe medical services to be 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 diagnostic colonoscopy provided by a participating provider on July 2, 2020.
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you are being penalized for a biopsy. 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 $325 copayment for outpatient surgery/outpatient hospital. You have been asked to pay a $325 copayment for a diagnostic colonoscopy. The rules say that, if during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed. A diagnostic colonoscopy falls within the outpatient surgery/outpatient hospital 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 diagnostic colonoscopy provided by a participating provider on July 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Farxiga 10 mg tablet.
You asked the Plan to pre-approve Farxiga. You say that this service is medically necessary. The Plan denied
your request. The Plan says this medication does not fall under 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 pre-approve Farxiga 10 mg tablet.
Benefits for Farxiga 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea custom fabricated abutment (D6057) and an implant supported crown (D6058) for tooth # 18.You asked the Plan to pre-approvethe dental services. You say that the enrollee had an implant surgically placed last year for tooth # 18. You say that the enrollee is in needs of the abutment and crown to complete the procedure. You say that if the implants are not restored with an abutment and crown, the implant will soon experience bone loss, pain and infection over time.The Plan denied your request. The Plan says custom fabricated abutment is not listedas a covered service. The Plan says that implant supported crown is not listed as a covered service either.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 Evidence of Coverage clearly states that any services not listed are not covered.Therefore, we decided that the Plan does not have to pre-approvea custom fabricated abutment (D6057) and an implant supported crown (D6058) for tooth # 18.
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 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. You were admitted for 
right arm edema and left knee pain. Medical conditions are stable. There are no medical needs requiring 
inpatient admission. There are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record documents a need for physical and occupational therapy, it does 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea complete partial denture (D5110).You asked the Planto pre-approvethe dentures. You say that this should be paid for.The Plandenied your request. The Plansaysthis is not covered as it exceeds the benefit allowance.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, which say that dentures are covered once every five years.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. Dentures were last received on February 11, 2019,less than five years ago.Therefore, we decided that the Plandoes not haveto pre-approvea complete partial denture (D5110).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Methotrexate 2.5mg tablet medication.
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this medication is not a covered benefit under the member's contractual policy.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Methotrexate 2.5mg tablet medication.
Benefits for this medication 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecore buildup on tooth #7 and #9 for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe radiographs do not show evidence of severe decay or trauma that would require core buildups prior to preparing the teeth for crowns.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the services when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the documentation provided did not clearly show sufficient coronal breakdown to warrant core buildups (D2950) for teeth #'7 and #9.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvecore buildup on tooth #7 and #9 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approveadditional test strips and lancets (2x daily testing) for the enrollee.You asked the Plan to pre-approveadditional test strips and lancets. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that that this request does not meet Medicare criteria for medically necessary and reasonable.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 additional test strips and lancets. Our reviewer says that the requested additional test strips and lancets are considered medically reasonable and necessary in this case. A request for twice daily use of lancets and test strips was made related to severe anxiety attacks if the enrollee doesn't know his glucose level at least twice daily. He was noted to have had a stroke one time he had a panic attack, so preventing the panic attacks via an extra lancet and test strip per day is reasonable and medically necessary for this particular patient. Our physician reviewer found that the enrollee's condition meets Medicare criteria for additional test strips and lancets.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional test strips and lancets have been met.Therefore, we decided that the Plan has to pre-approveadditional test strips and lancets (2x daily testing) 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/or send us the new information. This doesnot happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvephysical therapy to be provided by an out of network (OON) provider.You asked the Plan to pre-approvephysical therapy. You say that you would like to go to this provider because you feel like they can specifically help you.The Plan denied your request. The Plan says there are in-network providers available for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvephysical therapy to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora CT scan provided on June 24, 2020.You asked the Plan to waive the copayment fora CT scan. You say that you disagree with the charges because it took so long to receive the CT scan.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 $250 copayment for advanced imaging services provided in an outpatienthospital facility. You have been asked to pay a $250 copayment for a CT scan. A CT scan 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 fora CT scan provided on June 24, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe intraocular lens upgrade provided during a cataract surgery on September 9, 2020.You asked the Plan to pay forthe lens upgrade. You say that you feel that you should not have to pay more the a $295 copayment plus a $45 consultation copayment. You do not believe that you should have to pay the $1600 or the $165 for prescriptions.The Plan denied your request. The Plan says the copayment was correctly applied for the surgery. The additional cost for an upgraded lens is not covered by Medicare. You agreed to have this upgrade.The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL or a P-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the upgraded lens and a conventional IOL. While this upgraded lens may be appropriate for you, Medicare does not cover this service, and the provider is allowed to charge you for the upgrade.Therefore, we decided that the Plan does not have to pay forthe intraocular lens upgrade provided during a cataract surgery on September 9, 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 the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.The Plan must followMedicare 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 thePlan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does notrequire an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for below the knee amputation and transferred to skilled nursing on January7, 2021, where he is currently residing. There is ongoing weakness. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs.The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ultrasound guided single tendon sheath injection of Depo-Medrol provided on May 22, 2020.You asked the Plan to pay forthe ultrasound guided single tendon sheath injection of Depo-Medrol. You say that the ultrasound guided single tendon sheath injection of Depo-Medrol was medically necessary.The Plan denied your request. The Plan says the ultrasound guided single tendon sheath injection of Depo-Medrol was not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the ultrasound guided single tendon sheath injection of Depo-Medrol. Our reviewer says that the ultrasound guided single tendon sheath injection of Depo-Medrol was not medically necessary. Our physician reviewer found the Procedure code 76942 (ultrasonic guidance for needle biopsy, radiological supervision and interpretation), 20550 (injection, tendon sheath, ligament, trigger points or ganglion cyst), J1040 (injection, methylprednisolone 80 milligram) on date of service 5/22/20 is not medically necessary. The documentation on 5/22/20 does not support that the enrollee had evidence of a trigger point with a twitch response and referred pain on exam. The enrollee had subjective symptoms more consistent with lumbar radiculitis and the 5/22/20 performed procedure would not be considered effective for this condition or furnished in accordance with accepted standards of medical practice for the treatment of the enrollee's radicular symptoms. Furthermore, the documentation is not clear what conservative treatment the enrollee has completed. There was a referral to therapy but there are no objective documents indicating failure of therapy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ultrasound guided single tendon sheath injection of Depo-Medrol have not been met.Therefore, we decided that the Plan does not have to pay forthe ultrasound guided single tendon sheath injection of Depo-Medrol provided on May 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemassage therapy.You asked the Plan to pre-approvethe therapy. You say that you are in a lot of pain.The Plan denied your request. The Plan says this is a not covered benefit.The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist.Therefore, we decided that the Plan does not have to pre-approvemassage therapy
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services providedon September 30, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.Medicare rules say that planscan 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 Plandid not pre-approve the physician's services.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 physician's services providedon September 30, 2020