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

We decided that the Plan does not have to pay for the medical services provided February 25, 2020, to 
February 28, 2020. 
 
You asked the Plan to pay for the medical services. You say that the member was not enrolled in hospice care 
during the relevant dates of service. The Plan denied your request. The Plan says upon discharge or revocation 
of hospice care, fee-for-service Medicare continues to cover the beneficiary through the end of the month when 
the beneficiary revokes or is discharged from hospice alive. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 25, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the medical services 
provided February 25, 2020, to February 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for an out-of-network office visit. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says services can be redirected to network providers. 
 
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-approve 
a referral for an out-of-network office visit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 10, 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 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 
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 provided on July 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport you had on March 
5, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you have a service 
contract with the ambulance company, so you shouldn't have to pay the copayment. The Plan denied your 
request. The Plan says you were charged this copayment 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 $250 
copayment for ambulance transport services.  
 
You have been asked to pay a $250 copayment for the ambulance transport.  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.  If you have a separate contract with the ambulance 
company, then you will have to contact them  directly, as your Plan is not responsible for that benefit. 
Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport you had 
on March 5, 2020.
Appeal type: Practitioner Services
Decision: Favorable

   We decided that the Plan has to pre-approve an Epidural Steroid injection.

You asked the Plan to pre-approve an Epidural Steroid injection. You say that the requested Epidural injection is medically necessary.The Plan denied your request. The Plan says that the enrollee does not meet criteria for the requested Epidural Injection.


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 an Epidural Steroid injection. Our reviewer says that the requested Epidural injection is medically necessary. Our physician reviewer found the enrollee has chronic low back pain, is morbidly obese, is status post an amputation and is wheelchair bound. The enrollee is unable to effectively participate in physical therapy and has failed medication trials. Lumbar radiculopathy is listed as the diagnosis. The request is for an Epidural Steroid injection. The enrollee has lumbar radiculopathy, is morbidly obese, wheelchair bound and unable to participate in physical therapy. The enrollee has a L5 pars defect documented on MRI. The request is medically reasonable and 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 an Epidural Steroid injection have been met.Therefore, we decided that the Plan has to pre-approve an Epidural Steroid injection.

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 information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveTruxima for the enrollee.You asked the Plan to pre-approveTruxima. You say that Truxima is medically necessary.The Plan denied your request. The Plan says that that use of this form of rituximab is not supported.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 Truxima. Our reviewer says that Truxima is medically reasonable and necessary for the enrollee in this case. Truxima is FDA-approved for Waldenstoms and autoimmune hemolytic anemia. The documentation supports that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. Our physician reviewer found that the enrollee's condition meets Medicare criteriafor Truxima.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Truxima have been met.Therefore, we decided that the Plan has to pre-approveTruxima for the enrollee.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 toopen the case again, we will send you a letter
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on June 25, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
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 June 25, 2020. 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 provided on June 25, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve11 further physical therapy (PT) visits.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says one visit is approved and 11 further 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 these services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific and effective therapy for the enrollee's condition. He has had extensive therapy for this condition and it does not appear that he requires the ongoing unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The enrollee has been authorized an additional session to review   an independent exercise program. The specialized skill, knowledge and judgment of a qualified therapist is not 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve11 further physical therapy (PT) visits.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide 8 additional routine transportation trips.
You asked the Plan to provide 8 additional routine transportation trips. You say that you need transportation to your appointments. The Plan denied your request. The Plan says your benefit has been exhausted for 2020.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide 8 additional routine transportation trips.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran electrocardiogram (93005) performed on September 23, 2019.You asked the Plan to waive the copayment foran electrocardiogram. You say that you were told by the provider that the surgical copayment would be all that you would owe.The Plan denied your request. The Plan says the correct copayment 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 $40 copayment for diagnostic procedures and tests. You have been asked to pay a $40 copayment for an electrocardiogram. An electrocardiogram 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 foran electrocardiogram (93005) performed on September 23, 2019.Your complaint about receiving erroneous or misleading information about your cost-sharing responsibility from a representative of the provideris not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that these services are medically necessary for the enrollee.The Plan denied your request. The Plan says that there is no clinical advantageof LTACH over acute hospital.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. The enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fora drug test (G0483) provided on June 1, 2020.You asked the Plan to pay forthe drug test. You say that you would like reconsideration based on the records submitted.The Plandenied your request. The Plan says the documentation submitted does not include a physician order stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug test have not been met. The record does not include a physician order which states exactly what tests were to be performed. There is no evidence that the ordering provider requested a drug test for 22 or more classes.Therefore, we decided that the Plan does not have to pay fora drug test (G0483) provided on June 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe initial periapical x-ray (D0220) and 3 additional periapical x-rays (D0230) provided on July 14, 2020.You asked the Plan to pay forthe x-rays. You say that you were not aware that the type of x-rays being taken would not be covered. You say that you are unsatisfied with this bill. You also say that the services should be covered.The Plan denied your request. The Plan says periapical x-rays are not listed as covered services.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 periapical x-rays that you receivedare not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe initial periapical x-ray (D0220) and 3 additional periapical x-rays (D0230) provided on July 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadjustable arm height option (E0973) and manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory (E1028).You asked the Plan to pre-approveadjustable arm height option (E0973) and manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory (E1028). You say that the requested adjustable armheight option (E0973) and manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory (E1028) are medically necessary.The Plan denied your request. The Plan says the requested adjustable arm height option (E0973) and manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory (E1028) 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 adjustable arm height option (E0973) and manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory (E1028). Our reviewer says that the requested adjustable arm height option (E0973) and manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory (E1028) are not medically necessary. Our physician reviewer found the enrollee iswith a past medical history of Parkinson's disease and gait abnormality who requires a group 3 power wheelchair for mobility. Based on the medical records provided there is no documentation that the adjustable arm height option (E0973) and manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory (E1028) at issue in this case are medically reasonable and necessary. The provided medical records do not document a need for an adjustable arm height option.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of adjustable arm height option (E0973) and manual swingaway, retractable or removable mounting hardwarefor joystick, other control interface or positioning accessory (E1028) have not been met.Therefore, we decided that the Plan does not have to pre-approveadjustable arm height option (E0973) and manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory (E1028).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Faslodex (J9395) 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 that the plan has determined that the off-label use of this drug is not medically accepted.
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 the drug. Our reviewer says that the
requested drug is medically reasonable and necessary. Our physician reviewer found treatment of hormonereceptor
(HR)-positive advanced breast cancer in postmenopausal women with disease progression following
endocrine therapy is approved and appropriate. This enrollee had progression following letrozole. The
documentation does support that the requested drug is safe and effective and other reasonable and necessary 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 been met. Therefore, we decided that the Plan has to pre-approve
Faslodex (J9395) for the enrollee.
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 enrollee needs physical therapy.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with COVID-19 pneumonia. Her medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. She does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not areasonable expectation that the enrollee 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-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 13, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid
in full. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the
member's primary care physician did not refer 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 for physician services provided on February 13, 2020
by an out of network (OON) provider.