Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on March 2, 2020, and a computerized tomography (CT) scan provided on February 23, 2021.

You asked the Plan to waive the copayment for inpatient hospital care and CT scan. You say that the services should be covered. The Plan denied your request. The Plan says the cost share 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 10% coinsurance for inpatient hospital care.

You have been asked to pay a 10% coinsurance for inpatient hospital care and a $150 copayment for a CT scan. These services fall within the inpatient hospital care and outpatient diagnostic tests and therapeutic services and supplies benefit categories. 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 on March 2, 2020, and a computerized tomography (CT) scan provided on February 23, 2021.
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 the service is medically necessary.The Plan denied your request. The Plan says the service is not medically necessary or reasonable.

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 does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care.

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. Specifically, medically necessary services are available at the enrollee's current level of care. This means admission to a LTACH is not medically necessary or reasonable.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal (D3310) for tooth # 22, and clinical crown lengthening (D4249) for tooth # 22.

You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The Plan denied your request. The Plan says root canal is not listed as a covered service. The Plan says that clinical crown lengthening is not listed as a covered service either.

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 a root canal (D3310) for tooth # 22, and clinical crown lengthening (D4249) for tooth # 22.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a urologist office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an OON urologist office visit. You say that you do not trust doctors in Massachusetts. The Plan denied your request. The Plan says the requested service is 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 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 urologist office visit to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve low dose brachytherapy as monotherapy for high-risk prostate cancer (77316, 77761, 77790, 55860).

You asked the Plan to pre-approve the radiation therapy. You say that you ask for LDR as monotherapy for this enrollee and ask that the Plan approves its use.The Plan denied your request. The Plan says brachytherapy as monotherapy for high-risk cancer is considered investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.We looked at the file and Medicare rules. 

Based on this information, we decided that Medicare rules for coverage of the radiation therapy have not been met.Therefore, we decided that the Plan does not have to pre-approve low dose brachytherapy as monotherapy for high-risk prostate cancer (77316, 77761, 77790, 55860).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy (77523, 77522, 77525,
77263, 777334, 77470, 77321, 77370, 77301, 77338, 77300, 77293, 77427, 77336, 77014, 77387, G6002,
77280, 77290).

You asked the Plan to pre-approve proton beam therapy. You say that although an entity may be new does not
mean that it's not a proven, safe and good product. You formally request the Plan reconsider the denial for
treatment and allow this Proton therapy to be paid using Medicare guidelines. The Plan denied your request.
The Plan says per NCCN guidelines proton beam therapy is considered not medically necessary for the
treatment as there is no proven advantage for proton beam radiation therapy in prostate cancer.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of proton beam therapy have not been met. Therefore, we decided that the Plan does not have to preapprove
proton beam radiation therapy (77523, 77522, 77525, 77263, 777334, 77470, 77321, 77370, 77301,
77338, 77300, 77293, 77427, 77336, 77014, 77387, G6002, 77280, 77290).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on December 9, 2020.

You asked the Plan to pay for the laboratory services. You say that you receive specimens and are obligated to provide the service. You say that the client was not aware of authorization information prior to the services being performed and payment at the contracted rate should be made. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.

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 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 laboratory services provided by an out-of-network provider on December 9, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 29 individual psychotherapy sessions (90837) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the psychotherapy sessions. You say that you were in crisis and found a referral through another counselor you had worked with in the past. You are asking for coverage because the Plan was not able to provide the services that are covered in your plan. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 29 individual psychotherapy sessions (90837) to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain.

You asked the Plan to pre-approve a PET scan of the brain. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that an FDG PET scan is considered reasonable and necessary under certain circumstances.

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 a PET scan of the brain. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case you are not noted to meet diagnostic criteria for both AD and FTD. Nor are you noted to have been formally evaluated for "specific alternate neurodegenerative diseases or other causative factors, but the cause of the clinical symptoms remains uncertain". In this setting/context the requested services would not meet the NCD requirements for coverage and therefore would not be eligible for coverage. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET scan of the brain have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain.
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 these services are medically necessary.The Plan denied your request. The Plan says that you do not have complex nursing and medical management needs requiring a resource intensive inpatient hospital 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 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 

You were admitted for surgical repair of a hip fracture after a fall. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.

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 Prolia.

You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prolia.

Benefits for Prolia may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve auricular electroacupuncture device.

You asked the Plan to pre-approve auricular electroacupuncture device. You say that this device is medically necessary.The Plan denied your request. The Plan says this request is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that an auricular peripheral nerve stimulation device is not covered. We looked at the file and Medicare rules. The rules show that this device is not covered by Medicare or the Plan. 

Based on this information, we decided that Medicare rules for coverage of auricular electroacupuncture device have not been met.Therefore, we decided that the Plan does not have to pre-approve auricular electroacupuncture device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nivolumab 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 the requested treatment is not in the order recommended by the NCCN.

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 indicates that the NCCN does not support Nivolumab use alone as a single agent in this setting and recommends other options that have shown better data for success in treating the enrollee's medical condition. The provider states in the notes that the enrollee was previously on Keytruda. There are no distant metastases, and the cancer is EGFR, ALK, and PD-L1 negative. 

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 Nivolumab for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on March 13, 2021.
You asked the Plan to pay for the ambulance services. You say that 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 March 13, 2021. 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 March 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nerve testing (95886, 95907, 95999) performed May 21, 2020.
You asked the Plan to pay for the nerve testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 95886, 95907, & 95999 are not supported in the medical record. Specifically, the technical reports provided do not describe the procedures billed. The technical report did not include documentation of nerve conduction studies, for 1-2 studies. Based on this information, we decided that Medicare rules for coverage of the nerve testing have not been met. Therefore, we decided that the Plan does not have to pay for nerve testing (95886, 95907, 95999) performed May 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
You asked the Plan to pre-approve a pneumatic compression device. You say that the enrollee cannot use a basic pump. The Plan denied your request. The Plan says the requirements for coverage have not been met.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telephone evaluation and management service provided on July 6, 2020 by an out of network provider.
You asked the Plan to pay for the telephone evaluation and management service (99443). You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request prior authorization for the 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 had network providers available who could have provided 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 this service. Therefore, we decided that the Plan does not have to pay for the telephone evaluation and management service provided on July 6, 2020 by an out of network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on August 6, 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. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the rendering facility is also out-of-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 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 August 6, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve round-trip, non-emergency car transportation between the hospital and your home.

You asked the Plan to pre-approve the transportation services. You say that you need a ride to and from your outpatient procedure that includes sedation. You say that you are not allowed to drive. You say that your doctors will not release you to a regular ride service. You also say that you do not have another source or transportation. The Plan denied your request. The Plan says transportation between the hospital and your home is not a covered service.

The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Medicare rules for coverage of the transportation services have not been met. Specifically, this service is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve round-trip, non-emergency car transportation between the hospital and your home.