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

We decided that the Plan does not have to pre-approve SNF admission and services.You asked the Plan to pre-approve SNF services. You say that you need to build your strength to get out of bed.The Plan denied your request. The Plan says you have no skilled nursing or therapy needs.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 services. Our physician reviewer found that you were recently discharged from the hospital. You can walk 150 feet, attend to toileting needs, and do transfers. There are no skilled nursing services required. You will need physical and occupational therapy visits daily. However, thedaily skilled services do not need to be provided only on an inpatient basis in a SNF.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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ABPM (CPT Code A4670) provided to the enrollee on September 7, 2019.
You asked the Plan to pay for the ABPM. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ABPM have not been met. The ABPM is only covered for suspected white coat hypertension, and must be performed for at least 24 hours to meet coverage criteria. ABPM is not covered for any other uses. Therefore, we decided that the Plan does not have to pay for the ABPM (CPT Code A4670) provided to the enrollee on September 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the general anesthesia provided on May 24, 2019.
You asked the Plan to reimburse you for the dental service. You say that the anesthesia you received should be
covered under your medical benefit. The Plan denied your request. The Plan says anesthesia is not listed a
covered benefit.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or
replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not
covered or paid for by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the
general anesthesia provided on May 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the localized delivery of antimicrobial agents and odontoplasty provided on June 11, 2019.You asked the Plan to pay more for the localized delivery of antimicrobial agents and odontoplasty. You say that prior to the appointment they did not tell the enrollee that they no longer accept their insurance. You also say that the enrollee's usual provider was still on the list of in-network providers given to you by the Plan.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.Therefore, we decided that the Plan does not have to pay more for the localized delivery of antimicrobial agents and odontoplasty provided on June 11, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for medical supplies (HCPCS A4290) provided to the enrollee on September 14, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says test leads are a packaged service/item, and no separate payment can be made.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the definition of HCPCS code A4290 is "test leads." We find that HCPCS code A4290 is not supported in the medical record. Specifically, this code cannot be billed separately, as it is bundled into payment for CPT 64561. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for medical supplies (HCPCS A4290) provided to the enrollee on September 14, 2019.
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. The Plan denied your request. The Plan says that they did not receive documentation with information meeting step therapy criteria. 
 
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 Prolia is not medically reasonable and necessary in this case. You have a diagnosis of osteoporosis. You have not tried and failed zoledronic acid. You were unable to tolerate oral alendronate due to GI upset but this is not a contraindication to a trial of zoledronic acid. The plan's required drug zoledronic acid would not likely be less effective and/or likely have adverse effects for you than the requested drug. Our physician reviewer found that your condition does not meet step therapy criteria for Prolia. 
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary partial denture and mandibular partial denture provided on August 20, 2019.
You asked the Plan to pay for the maxillary and mandibular partial dentures. You say that you had this dental procedure done due to the condition of your teeth. You also say that this was a very expensive procedure and you were told you could request a reimbursement from the Plan. The Plan denied your request. The Plan says these dentures are not covered. The Plan also says that this provider was out-of-network.
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 without a prior authorization. Therefore, we decided that the Plan does not have to pay for the maxillary partial denture and mandibular partial denture provided on August 20, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy provided from August 14, 2019 through August 29, 2019.
You asked the Plan to waive the copayments for physical therapy. You say that you were told you needed physical therapy before getting an MRI. You say that you are appealing the bill. The Plan denied your request. The Plan says the copayments 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 $40 copayment for physical therapy at an in-network outpatient hospital. You have been asked to pay a total of $157.96 for physical therapy.
Date of Service
Service
Allowed Amount
Standard Copayment
Member Liability
August 14, 2019
Physical Therapy Evaluation
$81.19
$40
$40
August 15, 2019
Physical Therapy
$29.49
$40
$29.49
August 20, 2019
Physical Therapy
$29.49
$40
$29.49
August 27, 2019
Physical Therapy
$29.49
$40
$29.49
August 29, 2019
Physical Therapy
$29.49
$40
$29.49
TOTAL:
$157.96
Physical therapy falls within the "Outpatient rehabilitation 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 copayments for physical therapy provided from August 14, 2019 through August 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on June 4, 2019 by out of network provider
You asked the Plan to pay for an office visit. You say that the claim denied as missing authorization. You attached medical records to justify that the service rendered as medically necessary. The Plan denied your request. The Plan says it is important to know which providers are part of the network. Members may be required to use network providers to get their medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available, out-of-area dialysis, and cases in which the Plan authorizes the use of out-of-network providers. All services obtained from out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 an office visit (99214) provided on June 4, 2019 by out of network provider
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 need transportation to an appointment. The Plan denied your request. The Plan says that the request exceeds benefit limits.
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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Spinraza.
You asked the Plan to pre-approve Spinraza. You say that the requested Spinraza is medically necessary. The Plan denied your request. The Plan says that the requested Spinraza is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Spinraza. Our reviewer says that the requested Spinraza is medically necessary. Our physician reviewer found the enrollee has infantile spinal muscular atrophy (SMA), type I [Werdnig-Hoffman], which was diagnosed at the age of 10-14 months. His best milestone achieved is sitting unsupported. The plan denied coverage for Spinraza, stating that there is not enough medical evidence to support the use of this drug in people after the age of 15. Spinraza is indicated for the treatment of spinal muscular atrophy, with evidence favoring efficacy in both children and adults. Two neurologists caring for the enrollee write that Spinraza is now considered an effective therapy in accordance with generally accepted standards of medical practice for the treatment of adults with SMA. Providing Spinraza to those with SMA is the standard for medical practice. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Spinraza have been met. Therefore, we decided that the Plan has to pre-approve Spinraza.
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 physician's services provided on June 3, 2019.
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 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 physician's services provided on June 3, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing care facility services provided to the enrollee on
August 16, 2018.
You asked the Plan to pay for the services. You say that you depend on the facility for timely notification of the
enrollee's health insurance coverage. The Plan denied your request. The Plan says this was an untimely
submission of the claim.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the services was not filed until August 23, 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 care facility services provided to the enrollee on August 16, 2018
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 18, 2019.
You asked the Plan to waive the copayment for a specialist office visit. You say that you went for your annual wellness exam. You say that that was all that happened. 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 $45 copayment for physician/practitioner services/in-network/specialist's office. You have been asked to pay a $45 copayment for a specialist office visit. When additional services are provided outside of an annual wellness exam additional copayments are applied; therefore, the correct copayment has been applied. A specialist office visit falls within the physician/practitioner services/in-network/specialist's office benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of an additional anterior segment aqueous
drainage device (0376T).
You asked the Plan to pre-approve the insertion of an additional anterior segment aqueous drainage device.
You say that two stents are medically necessary. The Plan denied your request. The Plan says a second shunt is
not considered medically necessary.
The Plan must follow Medicare rules. Medicare rules say that additional insertions of anterior segment aqueous
drainage devices are considered not medically necessary.
We looked at the file and Medicare rules. The requested procedure is not considered medically necessary under
Medicare rules. Based on this information, we decided that Medicare rules for coverage of the insertion of an
additional anterior segment aqueous drainage device have not been met. Therefore, we decided that the Plan
does not have to pre-approve the insertion of an additional anterior segment aqueous drainage device (0376T).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you were unconscious and the ambulance
workers had to revive you. You say there was no need to the go to the hospital and you do not believe that you
should have to pay for the entire cost of the services. The Plan denied your request. The Plan says these
services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on February 23, 2018. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the services were not considered 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 pre-approve the services. Our reviewer says that the requested study is not considered medically reasonable and necessary in this case. Our physician reviewer found the requesting physician wishes to determine whether the enrollee's restless leg syndrome is affecting sleep. However, there is no data on how much the patient is actually using CPAP. If the enrollee is not adequately compliant with use (at least 4 hours per night, for at least 70% of nightS), then that may be the cause of the sleepiness.
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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a sleep study for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 21, 2019 through July 23, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was 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 inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found vitals were stable, blood testing was normal including troponin and BNP, lung, neuro, and heart examination was essentially normal, and they appeared euvolemic. Admission for monitoring was the next step, which based on the history and work-up was not expected to last more than 2 midnights. Therefore, this admission does not meet criteria.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 21, 2019 through July 23, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc One
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has unilateral primary
osteoarthritis of the left knee. She has not tried and failed the plan's required drugs of orthovisc and monovisc.
The records do not show that the required drugs would be less effective or contraindicated; therefore, Synvisc
One is not reasonable or medically necessary at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Synvisc One
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neudexta cap 20-10mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the prior authorization request indicates that the medication is to be self-administered.
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 Neudexta cap 20-10mg for the enrollee.