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

We decided that the Plan does not have to pay for skilled nursing services provided on June 18, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. 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 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 skilled nursing services provided on June 18, 2020
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe two additional intraoral periapical x-rays provided on July 30, 2020.You asked the Plan to pay forthe two additional intraoral periapical x-rays. You say that you were advised that your insurance would cover these services rendered by these treating providers.The Plan denied your request. The Plan says benefits for this service have been satisfied andthe frequency limitation has been exceeded.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, intraoral x-rays are limited to one procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on July 30, 2020, and your intraoral x-rays benefit had been exhausted.Therefore, we decided that the Plan does not have to pay forthe two additional intraoral periapical x-rays provided on July 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services received on February 28, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says these services were received 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 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 laboratory services received on February 28, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transfer to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF services. You say that you are too fragile to be home without constant help.The Plan denied your request. The Plan says the services you need can safely be received in the current inpatient rehab facility.

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 you have been receiving care at an inpatient rehab facility. The records do not show that daily skilled services can be provided only on an inpatient basis in a SNF. 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 pre-approve transfer to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for rubidium rb-82, diagnostic (A9555) injection, Regadenoson (J2785) cardiovascular stress test (93015) myocardial imaging, positron emission tomography (PET) perfusion study (78492) provided June 19, 2020.
You asked the Plan to waive the copayment for the diagnostic services and injection services. You say that you ask for review of the claim and consider an adjustment on the amount remaining due and being billed to you by the provider. The Plan denied your request. The Plan says the claim processed with the correct cost shares applied per the Evidence of Coverage.
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 the $400 deductible 20% for each medical supply, 20% coinsurance for each Medicare Part B drug and non-chemotherapy drugs to treat cancer, $25 copayment for non-radiological diagnostic services and $30 copayment for radiological diagnostic service, not including x-rays. You have been asked to pay $622.42 ($400 (deductible) + $120 (20% medical supply) + $47.42 (20% Part B Drug) + $25 (copay) +$30 (copay) = $622.42) for the diagnostic services and injection. The diagnostic and injection services fall within the Medicare Part B Prescription Drugs, Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 rubidium rb-82, diagnostic (A9555) injection, Regadenoson (J2785) cardiovascular stress test (93015) myocardial imaging, positron emission tomography (PET) perfusion study (78492) provided June 19, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ambulance transportation for a skilled nursing facility
(SNF) transfer.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the transportation is not medically necessary.
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 these services. Our reviewer says that
the transportation is not medically necessary. Our physician reviewer found the enrollee had a bladder infection
and COVID-19 infection. He is receiving oxygen and physical and occupational therapy. He no longer has
COVID-10 but has been accepted to an alternate SNF that is not a designated COVID-19 facility. Medicare
guidelines state ambulance services are a covered benefit for transport to the nearest facility with the
appropriate facilities. Documentation does not outline services at the new facility not available or provided at
the current facility. Without this documentation, medical necessity for the ambulance transfer is not supported.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve ambulance transportation for a skilled nursing facility (SNF) transfer.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient surgeries provided on August 3,
2020.
You asked the Plan to waive the coinsurance for the outpatient surgeries. You say that you have had the same
surgery before and was not charged. The Plan denied your request. The Plan says you were charged this
coinsurance 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%
coinsurance for Outpatient Hospital Services.
You have been asked to pay 20% coinsurance for the outpatient surgeries. The outpatient surgeries fall within
the Outpatient Hospital 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 coinsurance for
outpatient surgeries provided on August 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveBotox injections for migraine treatment once every 10 weeks.You asked the Plan to pre-approvethe requested injection frequency. You say that you feel you need these injections more frequently because your migraines return approximately 10 weeks after each treatment with almost daily headaches.The Plan denied your request. The Plan says this cannot be covered more than once every 12 weeks.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 requested injection frequency. Our reviewer says that the requested frequency of Botox injections is not shown to be medically reasonable and necessary. Our physician reviewer found in this case a request has been made for coverage of Botox injections to be performed every 10 weeks rather than every 12 weeks. The studies that have been done to date involving Botox (in chronic migraine as well as other indications) have only evaluated dosing of the drug every 12 weeks. There have not yet been any well-designed clinical studies completed to date formally evaluating dosing every 10 weeks. While there are also some publications that make note of a "wearing off phenomenon", these publications are retrospective and preliminary in nature. Given the need for further study of the proposed dosing interval of Botox sought in this case, it cannot be determined to be reasonable and necessary at this time.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 injection frequency have not been met.Therefore, we decided that the Plan does not have to pre-approveBotox injections for migraine treatment once every 10 weeks.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are 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 above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not medically necessary. Our physician reviewer found the records show that you were admitted to the hospital for respiratory failure after a house fire. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical conditions are stable,and you have no complex nursing or rehab needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive 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.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided from November 6, 2019, to
November 7, 2019.
You asked the Plan to pay for the services provided. You say that the enrollee wanted surgery before traveling
back to his city. The Plan denied your request. The Plan says the services were not urgent, emergent and
authorization was not requested.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and
pre-approved care.
We looked at the file, and Medicare rules. The file shows that the enrollee received an elected procedure. The
need for services was known prior to receiving the services. The Plan did not pre-approve the services at issue.
Based on this information, we decided that Medicare rules for coverage of the services provided have not been
met. Therefore, we decided that the Plan does not have to pay for the medical services provided from
November 6, 2019, to November 7, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested acupuncture services.
You asked the Plan to pre-approve the acupuncture services. The Plan denied your request. The Plan says this
provider is a standalone acupuncturist practicing in her own space. This provider is not an auxiliary personnel
furnishing acupuncture under the appropriate level of supervision of a physician, physician assistant, or nurse
practitioner/clinical nurse specialist.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to twelve sessions per ninety-day period, and no more
than twenty sessions per year. These treatments may be provided by a physician in accordance with state
requirements, or by physician assistants, nurse practitioners/clinical nurse specialists, and auxiliary personnel if
they meet certain licensure requirements. Auxiliary personnel furnishing acupuncture must be under the
appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist
We looked at the file and Medicare rules. The file shows that the requested provider is a standalone
acupuncturist practicing in her own space. This provider is not an auxiliary personnel furnishing acupuncture
under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical
nurse specialist. Therefore, we decided that the Plan does not have to pre-approve the requested acupuncture
services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided by you on June 24, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive
order for treatment in place. 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 June 24, 2020. 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 by you on June
24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the services can be safely received in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The patient is living at home with no recent hospitalization and has increasing fatigue and back pain. Medical
conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing
or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record
documents a need for physical and occupational therapy, it does not document a need for an intensive
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visits (99350) provided from July 31, 2020, to September 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for OON home visits. You say that authorization should not be required due to COVID-19. The Plan denied your request. The Plan says OON services require 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 for the home visits (99350) provided from July 31, 2020, to September 11, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan does not have to pre-approve out of network providers for physical therapy.
You asked the Plan to pre-approve out of network providers. You say that you prefer to use the requested
providers. The Plan denied your request. The Plan says there were providers in network who could render these
services. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus' rationale
for the overturn was that there were no available in network providers located within reasonable distance and
travel time from the member's home who can provide physical therapy. The Plan says that internal records
show that you are aware that your PCP is located in a different county than where you
currently reside, however you chose to enroll with out of network provider.
Your residence is 50.8 miles away from your PCP's address. Your permanent address has been in there since 2016. You selected the facility as your primary care provider. The records show you have
been receiving all of your medical care from in-network providers without any issues. The Plan
says that since the out of network is located in elsewhere, they are not obligated to expand their
network of providers outside that area.
The Plan is correct in this case. 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 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 records show your treatment history with
providers show you are well aware of the rules for getting care in network. Therefore, we decided that the Plan
does not have to pre-approve out of network providers for physical therapy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTrazimera.You asked the Plan to pre-approveTrazimera. You say that molecular studies indicate a response as a target therapy.The Plan denied your request. The Plan says the drug is not approved for pancreatic cancer.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Trazimera. Our physician reviewer found that the enrollee has pancreatic cancer. The requested use of Trazimera is not FDA-approvedfor the enrollee's diagnosis. Prior studies have not shown efficacy with the use of Trastuzumab in pancreatic patients,even when tumors express HER2 positivity. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrolleeWe looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Trazimera have not been met.Therefore, we decided that the Plan does not have to pre-approveTrazimera