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

We decided that the Plan does not have to pre-approve Nyvepria for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary as the enrollee is waiting for therapy to begin. 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 services are not medically reasonable or necessary. Our physician reviewer found 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 Nyvepria for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS)
device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no evidence of enrollment in a clinical trial.
The Plan must follow Medicare rules. Medicare rules say that a TENS unit would be covered with enrollment
in a clinical trial.
There is no evidence of enrollment in a clinical trial. Based on this information, we decided that Medicare rules
for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve
a transcutaneous electrical nerve stimulation (TENS) device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Purewick female urine collection device (K1006, A4328, A5102).
You asked the Plan to pre-approve the Purewick female urine collection device. You say that you live alone and cannot make it to the bathroom or bedside commode and needs the purewick. You only have a caregiver 4 hours a day because you cannot afford any more time. You can't afford it. The Plan denied your request. The Plan says the enrollee does not meet the coverage criteria.
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 the Purewick female urine collection device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Purewick female urine collection device (K1006, A4328, A5102).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), an intraoral periapical radiographic image (D0220), a crown (D2740), a core buildup (D2950), and protective restoration (D2940) provided on January 6, 2021.
You asked the Plan to pay for a limited oral evaluation, an intraoral periapical radiographic image, a crown, a core buildup, and protective restoration. You say that you were not aware that the provider had opted out of Medicare. The Plan denied your request. The Plan says you are responsible for services provided by privately contracted providers. The Plan will not reimburse for charges incurred by Medicare Opt Out providers.
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 limited oral evaluation, an intraoral periapical radiographic image, a crown, a core buildup, and protective restoration have not been met. Specifically, services were provided by an Opt Out provider. The Plan does not cover dental services when provided by an Opt Out provider. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), an intraoral periapical radiographic image (D0220), a crown (D2740), a core buildup (D2950), and protective restoration (D2940) provided on January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
March 15, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are
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 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
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 services provided by an out-of-network provider on March
15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve 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 unproven procedures are considered not reasonable and necessary and are not covered by Medicare.
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 the MRI does not demonstrate Modic Type 1 or 2 changes at the requested procedure level of L5 and S1. Furthermore, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures, including physical therapy. Additionally, there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. Overall, there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception.Therefore, the request for intraosseous ablation of the basivertebral nerve (Intracept) at L5-S1 is not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient visit provided on February 25, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for an outpatient visit. 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 referring provider 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 an outpatient visit provided on February 25, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7210) provided on April 27, 2021 by an OON provider.
You asked the Plan to pay for the extraction. You say that you needed to see a dental surgeon as an emergency because your tooth broke. You also say that your in-network dentist advised that they would not be able to pull your tooth, and the dental surgeon in the office was not available to schedule an appointment for another 2 weeks. The Plan denied your request. The Plan says this service was rendered by an OON provider. The Plan also says that non-emergency services provided by an OON provider are not available with this 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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the extraction (D7210) provided on April 27, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutments (D6057 x 2), and the abutment supported crown (D6058) provided on February 18, 2021.
You asked the Plan to pay for the custom fabricated abutments and 1 abutment supported crown. You say that the benefits booklet for 2021 notes (for In-Network) 70% coinsurance for adjustments to dentures, crown, denture reline up to 1 per year as well as the fitting and placing crown is an adjustment, and during the adjustment they have to make sure they are adjusted properly to work properly after they are placed. You also say that the custom fabricated abutment the custom fabricated abutment-includes placement abutment supported porcelain/ceramic crown is still a crown and since our insurance says crowns are covered it should be paid for at 70% which is noted in the booklet. The Plan denied your request. The Plan says 1 crown procedure is covered at 30% per calendar year. The Plan says that the frequency limit has been reached. The Plan also says that custom fabricated abutment 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 custom fabricated abutments are not among those covered under this benefit. This is an implant related service which is not covered by the Plan. Additionally, only 1 crown procedure is covered at 30% per calendar year. The record shows that the Plan paid for the abutment supported crown for tooth # 3, thus exhausting the benefit. Therefore, we decided that the Plan does not have to pay for the custom fabricated abutments (D6057 x 2), and the abutment supported crown (D6058) provided on February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse an additional amount for the complete upper denture (D5110) and the complete lower denture (D5120) provided on August 28, 2020, by an out of network dentist.
You asked the Plan to reimburse an additional amount for the dental services. You say that you were instructed by a customer service representative that you could get dentures and submit a claim for reimbursement. The Plan denied your request. The Plan says there is an 80% coinsurance for dental services that you receive out of network.
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 and dentures are listed as covered, there is an 80% coinsurance for dental services that are performed out of network. The record shows that the Plan provided a list of in network providers. The record also shows that a plan representative advised that the provider in this case was out of network, and you would be responsible for the 80% coinsurance. Therefore, we decided that the Plan does not have to reimburse an additional amount for the complete upper denture (D5110) and the complete lower denture (D5120) provided on August 28, 2020, by an out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral/facial photographic image (D0350) provided on May 14, 2021.
You asked the Plan to pay for the 2D oral/facial photographic image. You say that you were not advised that this service would not be covered by the Plan. The Plan denied your request. The Plan says this service is not a covered benefit.
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 2D oral/facial photographic image (D0350) provided on May 14, 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 these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower 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 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 mitral valve replacement. Your medical problems 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. 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. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services you received on November 19, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network services are not covered 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. The Plan only covers routine vision care provided by network providers. We looked at the file and the Plan's rules. The vision services in question were provided to you by an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the vision services you received on November 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on November 23, 2020.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the testing was
not approved by the ordering provider. 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. The file shows that the ordering physician listed on the claim did not authorize or order the testing at issue. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. Based on this information, we decided that Medicare rules for coverage have not
been met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on
November 23, 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 you need inpatient rehabilitation to return to your prior level of function. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your care can be safely provided 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 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 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. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home phototherapy unit.
You asked the Plan to pre-approve the requested unit. The Plan denied your request. The Plan says benefits of a light cabinet for home use are not medically appropriate for this enrollee.
The Plan must follow Medicare rules. Medicare rules say that ultraviolet cabinets are only covered under certain medical indications. We looked at the file and Medicare rules. The records provided do not indicate the enrollee has generalized intractable psoriasis. Based on this information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a home phototherapy unit.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the aflibercept injection provided on April 20, 2021.
You asked the Plan to waive the coinsurance for the aflibercept injection. You say that you did not pay anything before. You say that this should be covered in full and you cannot afford it. The Plan denied your request. The Plan says the coinsurance 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 20% of the cost for Part B drugs. You have been asked to pay $268.73, which is 20% of the allowed amount for the aflibercept injection. The allowed amount is $1,343.63 (20% x $1,343.63 = $268.73). The aflibercept 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 aflibercept injection provided on April 20, 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 admission to an IRF is medically necessary. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met, and the necessary services can be provided 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 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.