Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Tysabri 300mg/15ml vial (J2323).
You asked the Plan to pre-approve Tysabri 300mg/15ml vial. You say that the requested medication is necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
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 Tysabri 300mg/15ml vial. Our reviewer says that the medication is medically necessary. Our physician reviewer found the review has determined that the documentation supports that the Tysabri is medically reasonable and necessary for the enrollee. The documentation supports that the Tysabri 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 Tysabri 300mg/15ml vial have been met. Therefore, we decided that the Plan has to pre-approve Tysabri 300mg/15ml vial (J2323).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe outpatient mental health services (90832) provided on September 9, 2019 by an out of network (OON) provider. You asked the Plan to pay forthe outpatient mental health services. You say that you were told services would be covered and you have been seeing this provider for a while.The Plan denied your request. The Plan says there are in-network providers who can provide the services at issue.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 service 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 outpatient mental health services (90832) provided on September 9, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) admission and services.You asked the Plan to pre-approveSNF services. The Plan denied your request. The Plan says you do not require daily skilled services on an inpatient basis.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 from a nursing perspective, you have stable vital signs, and were treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at a modified to standby assist level for functional mobility. You require varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatientbasis in a skilled nursing facility setting.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 Plandoes not have to pre-approveskilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the nerve testing to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON nerve testing. You say that you feel this should be approved from the requested provider. The Plan denied your request. The Plan says there is no indication that the required nerve testing cannot be provided in-network. Since there is no network deficiency in access to this testing, the OON provider is not required.
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 the nerve testing to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSupartz FX.You asked the Plan to pre-approveSupartz FX. The Plan denied your request. The Plan says the enrollee has not met step therapyrequirements.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 Supartz FX. Our reviewer says that Supartz FX is not medically reasonable and necessary. Our physician reviewer found that the enrollee is noted to have osteoarthritis. A request has been made for Supartz, a hyaluronic acid injection, to treat the osteoarthritis. The health plan requires that other forms of hyaluronic acid injections be used. There is no evidence that the enrollee is allergic to or intolerant of these other forms of hyaluronic acid. There is no evidence that the enrollee has tried and not responded to these other forms of hyaluronic acid injections. There is no documentation as to why these other forms of hyaluronic acid would not be expected to be safe and effective for the enrollee. Therefore, the requested Supartz is not shown to be currently medically necessary and reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz FX have not been met.Therefore, we decided that the Plan does not have to pre-approveSupartz FX.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 15, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there are no benefits for 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 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 for the medical services provided to the enrollee by an out-of-network provider on October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on October 25, 2019.You asked the Plan to waive the copayment forthe specialist office visit. You say that you only saw the doctor for five minutes and you would like the claim to be reprocessed and paid in full.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 $35 copayment for provider and professional services at an in-network specialist's office. You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visitfalls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you were seen by the provider.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 forthe specialist office visit provided on October 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from November 25, 2019 through November 28, 2019.You asked the Plan to waive the copayment forthe inpatient stay. You say that this was an emergency. You say that it is out of your control if the facility was out-of-network.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 $325 copayment per day, days 1 to 5 for each in-network inpatient hospital stay.You have been asked to pay a $975 copayment for the inpatient stay. ($325/day x 3 days = $975). The inpatient stay falls within the "Inpatient hospital care" 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 forthe inpatient stay provided from November 25, 2019 through November 28, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on August 16, 2019 by an out of network (OON) provider.You asked the Plan to pay for the laboratory testing. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says the services were not urgent or emergent.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 provider in this case is not a network provider with the Plan. The ordering provider is not a network provider either. 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 the genetic testing provided on August 16, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve a Freestyle Libre continuous glucose monitor (CGM).You asked the Planto pre-approvethe CGM. You say that you feel that this should be covered.The Plandenied your request. The Plansaysyou do not meet the criteria for this device.The Plan must follow Medicare rules. Medicare rules say that CGMs may be covered for enrollees who require blood glucose testing four or more times per day and need three or more insulin injections which require frequent adjustment based on the results of blood sugar testing. In this case, the documentation indicates that you test twice per day and receive two 20-unitinsulin doses per day. As such, the criteria for the CGM have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea Freestyle Libre continuous glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay fornursing home facility care provided on June 3, 2019 by an out of network (OON) provider.You asked the Plan to pay fornursing home facility care. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained 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 foundno exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay fornursing home facility care provided on June 3, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora contact lens fitting service provided on October 14, 2019.You asked the Plan to pay forcontact lens fitting service. You say that you need this service due to a condition you have had since you were 29 years old.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this service is not covered by Medicare or the Plan.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.We looked at the file and the Plan's rules. This contact lens fitting service is not covered by the Plan's vision care benefits. Based on this information, we decided that the Plan's rules for coverage of contact lens fitting service have not been met.Therefore, we decided that the Plan does not have to pay fora contact lens fitting service provided on October 14, 2019
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 the enrollee has had a prolonged hospital stay and would benefit from transfer to the LTACH level of care.The Plan denied your request. The Plan says the enrollee can remain in the current hospital as long as it is necessary.The Planmust 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 patient is currently undergoing treatment at an ACH following surgical repair of a perforated marginal ulcer. Post-operatively, the enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee has been weanedfrom the ventilator. The enrollee is not currently deemed to be a candidate for decannulation. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs.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 intravenous immune globulin (IVIG) treatments.
You asked the Plan to pre-approve the requested services. You say that previous IVIG treatments had been working. The Plan denied your request. The Plan says there is no clinical indication for IVIG therapy.
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 requested services. Our physician reviewer found that you were once given a diagnosis of CIDP. However, upon examination from multiple neurologists, the diagnosis of CIDP was questioned, and was ultimately not supported by findings on examination and electrodiagnostic studies. Thus it cannot be said that you have a diagnosis of CIDP as current diagnostic standards have not been met. IVIG is not FDA approved for use in an idiopathic peripheral neuropathy, non-specific neuropathy, fibromyalgia or somatic pain disorder. The use of IVIG is not supported in a CMS approved medical journal for idiopathic peripheral neuropathy. Nor is the use of IVIG supported for any of your diagnoses. Therefore, the requested services are not 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve intravenous immune globulin (IVIG) treatments.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous radiofrequency ablation (ERFA) of varicose veins.
You asked the Plan to pre-approve the ERFA procedures. You say that the enrollee requires this treatment to treat her pain. The Plan denied your request. The Plan says since the enrollee's BMI is over 35, ERFA cannot be covered.
The Plan follows Medicare rules. Medicare rules say that varicose vein treatment is covered for symptomatic varicose veins which meet certain criteria and have failed to improve after a trial of conservative therapy, including weight loss to below a BMI of 35. 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 ERFA procedures. Our reviewer says that the requested procedures are not considered medically reasonable and necessary. Our physician reviewer found coverage requires that the patient's symptoms be attributable to the varicose veins to be treated. This patient is a 65-year-old woman with pain with walking with a history of hypertension, diabetes, hyperlipidemia, and documented abnormal lower extremity pulses. The patient continues with this pain despite what appears to be numerous previous vein procedures as there are several areas of absent vein on the most recent duplex and the patient is documented to be status post sclerotherapy. There is documentation of absent edema or skin changes in the lower extremities bilaterally. Therefore, the documentation does not satisfactorily attribute the patient's mobility limiting symptoms to her residual varicosities. The other criteria not met is that regarding BMI. Coverage criteria requires at the BMI to be less than 35. The patient's BMI is documented to be 41. 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 ERFA procedures have not been met. Therefore, we decided that the Plan does not have to pre-approve endovenous radiofrequency ablation (ERFA) of varicose veins.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient mental health care stay provided from September 24, 2019 to September 27, 2019.You asked the Plan to waive the copayment forthe inpatient mental health care stay. You say that this should not be charged as a mental health stay. The Plandenied 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 $225 per admission deductible and a $195 copayment per admission; per day, for days 1-7. You have been asked to pay a $225 per admission deductible and a $195 copayment for each day of the inpatientmental health care stay. ($195 x 3 days = $585). ($225 + $585 = $810). The inpatient mental health care stay falls within the "Inpatient mental health care" benefit category. The medical record shows you were treated for mental diseases and disorders.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 forthe inpatient mental health care stay provided from September 24, 2019 to September 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 9, 2019 by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-participating provider without 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 forthe medical services provided on October 9, 2019 by an out of network (OON) provider