Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay fora home visit for the evaluation and management of an established patient (99348) provided on July 10, 2019 by out of network provider.You asked the Plan to pay fora home visit for the evaluation and management of an established patient. You say that you have had your claims denied and are asking for a reconsideration based on the lack of options and rejection from the other house call providers in the area and the patient's limited mobility.The Plan denied your request. The Plan says the provider is a non-network provider with the member's health plan, and member self-directed. The member's network primary care physician (PCP) did not refer for services. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plandid 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 fora home visit for the evaluation and management of an established patient (99348) provided on July 10, 2019 by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required.You asked the Plan to pre-approve the core buildup. You say that a root canal and cavity are the problems affecting your heart. You also say that you must repair your teeth to do preventive care.The Plan denied your request. The Plan says this service is not covered by Medicare. The Plan also says that you do not have a supplemental benefit.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pre-approve 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 pre-approvea core buildup, including any pins when required.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services for the enrolee. You asked the Plan topre-approveIRF care. You say that the enrollee requires provision of rehab services due to functional impairments and medical complexity.The Plan denied your request. The Plan says the enrollee does not require active and ongoing therapeutic intervention of multiple therapy disciplines.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 seen to be walking with a rolling walker and assistance of one person. She requires supervision to contact guard assist for bed mobility and transfers with the walker. She can feed and groom with set up. She is at minimal assist for bathing, toileting, upper body dressing and moderate assist for lower body dressing. She has well-controlled pain. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional physical and occupational therapy, but does not require this on an intensive rehabilitation facility therapy program level 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-approveacuteinpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora chest x-ray (71046) provided on August 2, 2019 by out of network provider, "the hospital". You asked the Plan to pay forachest x-ray. You say that you went to urgent care for symptoms of pneumonia and they told you that they did not have an x-ray machine. You say you were referred to the hospital and it should be covered under an urgent care visit.The Plan denied your request. The Plan says the facility is out-of-network with your benefit plan and a prior authorization was needed and not obtained. Per your health plan benefit, a prior authorization is required before receiving out-of-network 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 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 fora chest x-ray (71046) provided on August 2, 2019 by out of network provider, "the hospital".
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve Keytruda for the enrollee.You asked the Planto pre-approve the drug. You say that this is medically necessary.The Plandenied your request. The Plansaysexperimental and investigational medications are not a covered benefit unless you are enrolled in a Medicare approved trial program.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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee's cancer is microsatellite stable and has tumor mutational burden of 10 mutations/Mb and no indication of PDL-1 activity. Keytruda is not FDA approved for use in breast cancer unless the cancer is microsatellite high or deficient mismatch repair and has no satisfactory alternative treatment. The drug is not supported in any of the CMS approved compendia. Therefore the documentation does not support that Keytruda is medically reasonable and necessary. And the documentation does not support that Keytruda is safe and effective 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 the drug have not been met.Therefore, we decided that the Plandoes not haveto pre-approveKeytruda for the enrollee
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat therapeutic facet joint injections.You asked the Plan to pre-approve injections. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan follows Medicare rules. Medicare rules say that injections are only covered for certain indications.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 injections. Our reviewer says that the documentation does not support that the requested injection services are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic back pain due to facet arthritis and degenerative disc disease. The medical records do not show physical exam findings indicating that the facet joints are the source of the enrollee's back pain. In addition, there is ongoing history that the pain radiates to the enrollee's legs and the member has had ongoing transforaminal epidural steroid injections (TFESI) injections for the same pain. Therefore, the enrollee does not meet criteria for the requested injections.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of injections have not been met.Therefore, we decided that the Plan does not have to pre-approverepeat therapeutic facet joint injections.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided by an out-of-network provider on January 28, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 forthe medical services provided by an out-of-network provider on January 28, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on August 12, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency for the 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 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 forthe medical services provided to the enrollee by an out-of-network provider on August 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehypoglossal nerve stimulation.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that procedure code 0466T is considered not reasonable and necessary.The services at issue are hypoglossal nerve stimulation described by procedure code 0466T. This code is denied by Medicare as not reasonable or medically necessary.Therefore, we decided that the Plan does not have to pre-approvehypoglossal nerve stimulation.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health nursing visits.You asked the Plan to pre-approve additional visits. You say that self-care has become more difficult, putting the enrollee at risk for medication safety issues.The Plan denied your request. The Plan says the enrollee can be educated to self-manage his disease with the approved visits.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.The file shows that 60 home health nursing visits were requested. The Plan has agreed to pre-approve 7 visits. 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 visits. Our physician reviewer found that the enrollee was recently admitted to acute care with hyperglycemia and confusion. Home health nursing is requested to help manage diabetes and improve compliance with medications. He currently uses insulin 3 times daily. Recent therapy notes indicate he is independent with mobility and activities of daily living. He is independent with homemaking and lives with his daughter. The records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessaryfor the enrollee beyond the 7 visits that have been approved by the plan.
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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approveadditional home health nursing visits
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture services to be provided.You asked the Plan to pre-approve acupuncture. You say that you have chronic pain and would rather receive acupuncture than pain medications.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because acupuncture is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.The services at issue in this appeal are acupuncture services.Therefore, we decided that the Plan does not have to pre-approve acupuncture services to be provided.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does nothave to pre-approveoffice visits (99201, 99205) to be provided by out of network provider, "the doctor". You asked the Plan to pre-approveoffice visits. You say that you are disputing the prior authorization denial.The Plandenied your request. The Plan says the records do not indicate a medical reason why you need to be seen out-of-network for services. The Plan says that in-plan providers are available. The Plan further says that your benefit package requires the use of in-network, contracted providers other than an urgent or emergency situations. Additionally, the records indicate that you are an established patient with "in network doctor" at "the medical group" and it is recommended that your care be continued there.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 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. 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-approveoffice visits (99201, 99205) to be provided by out of network provider, "the doctor".
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the drug combination Doxorubicin HCL, Gemcitabine, Paclitaxel, Ondansetron, and Pegfilgrastim.You asked the Plan to pre-approvethe requested drug combination. The Plan denied your request. The Plan says this combination is a fifth-line treatment. There is no support for this regimen as subsequent therapy.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested drug combination. Our physician reviewer found that the enrollee has metastatic neuroendocrine tumor of the bladder. The regimen proposed of Gemcitabine, Adriamycin, and Paclitaxel (GAT) has been studied as first line therapy for enrollees with unresectable or metastatic urothelial cancer. This enrollee has a neuroendocrine cancer, which is treated differently. This enrollee is not receiving first line but 5th line therapy, when single agent therapy is generally the standard of care. Therefore, the requested combination is not reasonable or 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 requested drug combination. have not been met. Therefore, we decided that the Plan does not have to pre-approvethe drug combination Doxorubicin HCL, Gemcitabine,Paclitaxel, Ondansetron, and Pegfilgrastim.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp (J0881).You asked the Plan to pre-approvethe Aranesp. You say that this service is medically necessary.The Plan denied your request. The Plan says the member's hemoglobin and hematocrit levels do not meet NCD criteria.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 the Aranesp. Our reviewer says that Erythropoietin is not recommended in patients being treated with curative intent and Folfirinox is not a palliative regimen. Inaddition, Retacrit would be the preferred agent. Our physician reviewer found the service is not reasonable or 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 Aranesp have not been met.Therefore, we decided that the Plan does not have to pre-approveAranesp (J0881).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 4, 2018 by out of network provider.You asked the Plan to pay for physician services. You say that you did not realize that you were not in the member's specific plan.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the primary care provider did not refer 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 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 forthe medical services provided on December 4, 2018 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services the enrollee.You asked the Plan to pre-approvethe LTACH services. The Plan denied your request. The Plan says the clinicals are not supporting a need for complex care.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 physician reviewer found that LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory treatments with oxygen supplementation and BiPAP, intravenous antibiotics, surveillance laboratory studies, specialty consultations, and therapy services. The documentation does not support that the enrollee in this case requires services atthe LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered bythe health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal surgery (vertiflex).You asked the Plan to pre-approvespinal surgery. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are 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 pre-approve spinal surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has ongoing back pain. The requested device is experimental at this time. More research is needed. Therefore, the enrollee does not meet criteria for the requested services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal surgery have not been met.Therefore, we decided that the Plan does not have to pre-approvespinal surgery (vertiflex).