Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services you provided on October 03, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says services
provided by non-participating providers are not covered unless prior authorized by the Plan.
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 you provided on October 03, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 7 home health skilled nursing visits and 7 home health
aide visits.
You asked the Plan to pre-approve the home health skilled nursing visits and home health aide visits. You say
that you need your nursing visits until your catheter and J-tube are removed. You also say that the proper
skilled nursing visits and home health aide visits could prevent a life or death situation. The Plan denied your
request. The Plan says the medical need for daily nursing services is not supported. The Plan also says that the
enrollee has reached the maximum amount of skilled nursing and home health aide visits per the Medicare
guidelines.
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.
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 home health skilled nursing visits
and home health aide visits. Our reviewer says that the services do not meet the Plan's coverage criteria. Our
physician reviewer found the 7 denied skilled nursing visits are not required to effectively provide treatment,
care, and/or services which are medically necessary for you. Our reviewer also found that based on the medical
records provided, the 7 denied home health aide visits are not reasonable and necessary to the treatment of your
illness or injury by the skilled professional staff.
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 home health skilled nursing visits and home health aide visits have not been
met. Therefore, we decided that the Plan does not have to pre-approve 7 home health skilled nursing visits and
7 home health aide visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Vitamin B12 injection provided on
February 18, 2020.
You asked the Plan to waive the coinsurance for the injection. You say that you have never had to pay for these
shots before. The Plan denied your request. The Plan says that you pay 20% for each Medicare-covered Part B
drug obtained at a plan pharmacy/mail order location.
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 20%
coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a 20% coinsurance for the injection. The injection falls within the Medicare Part B
prescription drugs benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Vitamin B12
injection provided on February 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied
your request. The Plan says Medicare coverage criteria are not met.
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 preapprove
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 that based on the medical records, the
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. Your current medical status does not require intensive
physician or nursing oversight in an IRF. Your functional level does not require an IRF intensive level
program. Medicare coverage criteria are not met. 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 inpatient rehabilitation facility (IRF)
admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural.
You asked the Plan to pre-approve an epidural. You say that the requested epidural is medically necessary. The
Plan denied your request. The Plan says the requested epidural does not meet criteria.
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 an epidural. Our reviewer says that the
requested epidural does not meet criteria. Our physician reviewer found the enrollee is with neck and arm pain.
The medical records do not clearly show the cause of the enrollee's neck and arm pain. The diagnosis remains
unclear. Criteria for ESI have not been met.
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 have not been met. Therefore, we decided that the Plan does not
have to pre-approve an epidural.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the laboratory services provided on March
10, 2020 to March 12, 2020.
You asked the Plan to waive the copayments for the laboratory services. You say that you should not be
charged for both of the laboratory services. The Plan denied your request. The Plan says you have been
charged the correct cost sharing 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 $10
copayment for each basic imaging service (e.g., general x-rays or ultrasound).
You have been asked to pay a $10 copayment for the laboratory services on each date of service. The
laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit
category. The record shows you were charged separately for the laboratory services.
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 the laboratory services provided on March 10, 2020 to
March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the observation stay provided from March
4, 2020 through March 6, 2020.
You asked the Plan to waive the copayment for the observation stay. You say that you had to return to the
hospital. You say that you shouldn't have to pay for this service. The Plan denied your request. The Plan says
the copayment 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 $125
copayment after the deductible is met for outpatient hospital observation services.
You have been asked to pay a $125 copayment for the observation stay. The observation stay falls within the
"Outpatient hospital observation" 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
the observation stay provided from March 4, 2020 through March 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided January 16,
2020 to January 22, 2020.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the copayment should
be waived. The Plan denied your request. The Plan says the correct cost-sharing 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 $295
per day copayment for days 1-6 for Inpatient Care.
You have been asked to pay a $1,770 copayment for 6 days of inpatient care. 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 inpatient hospital care provided January 16, 2020 to January 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for
coverage of a LTACH admission.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is receiving necessary services in an acute care hospital at an appropriate
level of care. The acute care hospital is able to provide all of the services the enrollee requires. Additionally,
continued care at this level is appropriate until the enrollee is stable to transfer to a lower level of care such as
an inpatient rehabilitation facility, a skilled nursing facility or sub-acute rehabilitation facility.
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-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says care could be received in another setting.
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 enrollee was medically stable with no evidence of need for supervision by PMR
Physician. There is no need for acute rehab nursing care. Functionally given she is at minimum assist level, she
does not need IRF admission. You may benefit from further PT and an OT but does not require an intensive
therapy program. IRF admission is not medically necessary based on the enrollee's current functional status and
medical stability.
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied
your request. The Plan says Medicare coverage criteria are not met.
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 your nursing, medical and rehabilitation needs do not require an acute
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical status
does not require intensive physician or nursing oversight in an IRF. Your functional level does not require or
indicate that IRF care is required. Medicare coverage criteria are not met. 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 inpatient
rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Mvasi.
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 off-label use of this drug is not accepted.
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 review relates to a
request for Mvasi, a biosimilar Bevacizumab, to treat a woman with primary peritoneal cancer. It
will be used in combination with Gemcitabine and Carboplatin. Mvasi is not FDA approved to treat the
enrollee's cancer. There is insufficient clinical information to determine if the enrollee has platinum-sensitive
cancer. Therefore the submitted documentation does not support that the drug is medically reasonable and
necessary or that it 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 Plan does not have
to pre-approve Mvasi.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility for the
enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the services required can be provided at a SNF level of care.
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 the enrollee's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
does require skilled physical therapy and occupational therapy but based on the medical records provided the
enrollee does not require treatment in an intensive rehabilitation therapy program. There is concern that the
enrollee would not be able to fully participate in and benefit from the intensive rehabilitation therapy program
provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more
appropriate in this case.
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 admission to an inpatient rehabilitation facility for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that a LTACH admission is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving necessary services inan acute care hospital at an appropriate level of care. Theacute care hospital is able to provide all of the services theenrolleerequires. Additionally, continued care at this level is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility or sub-acute rehabilitation facility.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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two periodontal medicament carriers with peripheral seal
(D5994 x2) provided on March 2, 2020.
You asked the Plan to pay for the periodontal medicament carriers. You say that the only things done were
impressions for the gum medication trays, repair of three upper teeth and x-rays. You also say that you asked
the provider's office for an adjustment back on your card for the cleaning and gum trays, which you cancelled.
The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two
periodontal medicament carriers with peripheral seal (D5994 x2) provided on March 2, 2020.
Your complaint about being unhappy with the treating provider is 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Hepatitis A and Hepatitis B vaccines provided to the enrollee on March 6, 2020.
You asked the Plan to pay for the vaccines. The Plan denied your request. The Plan says these vaccines are not covered.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Hepatitis A vaccine. The Plan follows the same rules. Additionally, the Plan only covers the Hepatitis B vaccine with a high or intermediate risk of getting Hepatitis B. The records do not show that the enrollee have been injured or directly exposed to any illness related to the Hepatitis A vaccine. Additionally, the records do not show that the enrollee was at high or intermediate risk of getting Hepatitis B. Therefore, we decided that the Plan does not have to pay for the Hepatitis A and Hepatitis B vaccines provided to the enrollee on March 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CYP gene panel provided on January 23, 2020.
You asked the Plan to pay for the CYP gene panel. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that CYP gene panels are not covered. We looked at the file and Medicare rules. In this case, the file shows you billed for a CYP gene panel. These panels should be billed with a single code - CPT 81479. CYP gene panels that test for multiple CYP genes are not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the CYP gene panel have not been met. Therefore, we decided that the Plan does not have to pay for the CYP gene panel provided on January 23, 2020.