Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that the drug is medically necessary. The Plan denied your request. The Plan says the drug is not medically necessary.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the drug is not medically necessary. Our physician reviewer found a trial of drug zoledronic acid is required before the Plan will approve the requested drug. In this case, the patient has not tried and failed the required drug and there is no documentation provided indicating that the required drug would likely be less effective and/or likely have adverse effects 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 Prolia have not been met. Specifically, there is no evidence the Plan's preferred drug would be less effective for this enrollee then the requested drug. This means the step therapy requirements have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a filling (D2391), inhalation of nitrous oxide (D9230 x4), and application of desensitizing medicament (D9910) provided on March 5, 2020.
You asked the Plan to pay for a filling, inhalation of nitrous oxide, and application of desensitizing medicament. You say that you shouldn't have to pay for these services. The Plan denied your request. The Plan says you are not covered for this service when seen by an out-of-network provider.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a filling, inhalation of nitrous oxide, and application of desensitizing medicament have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these 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 a filling (D2391), inhalation of nitrous oxide (D9230 x4), and application of desensitizing medicament (D9910) provided on March 5, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pain management services provided on December 2, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for pain management services. You say that you would like this claim reprocessed and paid due to medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 had network providers available who could have provided 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 pain management services provided on December 2, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a custom fabricated abutment (D6057), and an abutment supported crown (D6058) provided on April 7, 2021.
You asked the Plan to pay for a custom fabricated abutment, and an abutment supported crown. You say that the services should be covered. The Plan denied your request. The Plan says the services at issue are not a covered service.
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 a custom fabricated abutment (D6057), and an abutment supported crown (D6058) provided on April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 42 fractions of proton beam therapy for the enrollee.
You asked the Plan to pre-approve the services. You say that the cure rates, complication rates, and survivability are all better with protons versus those of photons. The Plan denied your request. The Plan says there is no current research that prostate cancer responds better to proton beam therapy than intensity-modulated radiation therapy (IMRT), which would be approved.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found whether or not proton therapy (in general) affords any benefit over conventional radiation therapy is a heated issue, with quite disparate opinions among experts in the field. Whether proton therapy for prostate cancer affords any advantage over IMRT is very controversial. Any potential benefit or detriment of proton therapy over standard IMRT is an investigational question. Proton therapy will almost always reduce dose to surrounding normal tissues. Simply demonstrating that proton therapy will reduce the low dose to normal tissues does not necessarily demonstrate that it is clinically needed relative to IMRT though, as the reductions
should be clinically meaningful, and reduce toxicity risks in a clinically meaningful manner. To date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve 42 fractions of proton beam therapy for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit solution 3000 unit/ml for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there must be medical reason why the preferred drugs cannot be used.
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 the services. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found there is a
requirement for a trial of Aranesp, Mircera, or Retacrit before the plan will approve Procrit. In this case, the
enrollee has not tried and failed any of these drugs. There is no documentation provided indicating that the
plan's required drugs would likely be less effective and/or likely have adverse effects 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Procrit solution 3000 unit/ml for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya 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 step therapy guidelines were not followed.
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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the plan requires a trial of Remicade OR Inflectra; and Stelara before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the plan's required drugs would likely be less effective and/or likely have adverse effects 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 Ilumya for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency ambulance transportation (A0429, A0425), and non-emergency transportation (A0130, S0215) provided on May 13, 2021.

You asked the Plan to waive the copayment for emergency ambulance transportation, and non-emergency transportation. You say that the services were unnecessary. The Plan denied your request. The Plan says the copayment was 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 $100 copayment for each one-way trip for ambulance services. 

You have been asked to pay a $150 copayment for ambulance services. The services at issue fall within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency ambulance transportation (A0429, A0425), and non-emergency transportation (A0130, S0215) provided on May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 5, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for physician services. You say that you could not wait 9-12 months for prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 had network providers available who could have provided 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 5, 2021 by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve at the in-network cost share rate the replacement of aortic valve on heart-lung machine (33405) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve at the in-network cost share rate the replacement of aortic valve on heart-lung machine. You say that you would like this claim approved at the in-network cost sharing amount. The Plan denied your request. The Plan says they have in-network providers available in-network.
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 at the in-network cost share rate 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. These services are available using the Point-of-Service option but will not be paid at an in-network rate since providers are available. Therefore, we decided that the Plan does not have to pre-approve at the in-network cost share rate the replacement of aortic valve on heart-lung machine (33405) to be provided by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on December 4, 2020.
You asked the Plan to pay for the domiciliary or rest home visit. You say that you would like this claim to be reviewed for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit provided on December 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve trigeminal division block anesthesia (D9212) and first 15 minutes of intravenous moderate (conscious) sedation/analgesia (D9239).
You asked the Plan to pre-approve the trigeminal division block anesthesia and intravenous moderate (conscious) sedation/analgesia. The Plan denied your request. The Plan says these services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
trigeminal division block anesthesia (D9212) and first 15 minutes of intravenous moderate (conscious)
sedation/analgesia (D9239
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-ray (D0220) provided on April 1, 2021.

You asked the Plan to pay for the dental service. You say that you had recently gotten a crown to repair a damaged tooth. You say that a single x-ray was taken prior to getting the crown to ensure the tooth was otherwise okay. You also say that you feel this service should be covered under the circumstances. The Plan denied your request. The Plan says periapical x-ray is not listed as a covered service.

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-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periapical x-ray (D0220) provided on April 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an implant removal (D6100), a bone replacement graft (D7953), and a cone beam computed tomography image (D0383) provided on May 10, 2021.

You asked the Plan to pay for an implant removal, a bone replacement graft, and a cone beam computed tomography image. You say that the services should be covered. The Plan denied your request. The Plan says the services at issue are not covered benefits.

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 an implant removal (D6100), a bone replacement graft (D7953), and a cone beam computed tomography image (D0383) provided on May 10, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide (HHA) services (G0299) for 4 hours per day, 7 days per week, from June 6, 2021, to August 1, 2021.

You asked the Plan to pre-approve the home health aide services. You say that you need help with showering, food preparation and shopping. You say that you need help with chores and personal hygiene. You also say that you feel you need home health aide services for your own good. The Plan denied your request. The Plan says personal care and homemaker services are not covered by Medicare.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health aide services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve home health aide (HHA) services (G0299) for 4 hours per day, 7 days per week, from June 6, 2021, to August 1, 2021.
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 the service is medically necessary. The Plan denied your request. The Plan says the service is 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 in the Medicare rules section. 

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 you medical conditions are stable, and you have no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.

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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four (4) additional PT visits.
You asked the Plan to pre-approve additional PT visits. You say that additional PT visits are medically necessary. The Plan denied your request. The Plan says four (4) additional PT visits 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 four (4) additional PT visits. 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 that the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been instructed in and you are compliant in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your 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 four (4) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve four (4) additional PT visits.