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

We decided that the Plan does not have to pre-approve Trelegy Aer Ellipta.
You asked the Plan to pre-approve Trelegy Aer Ellipta. You say that the requested medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 Trelegy Aer Ellipta.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on September 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab tests. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was obtained for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We 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 lab tests provided on September 4, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a Positron Emission Tomography (PET) scan.
You asked the Plan to pre-approve PET scan. You say that the enrollee is due for her 6-month follow-up PET scan. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because surveillance PET scans are not indicated for the enrollee at this time.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically 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 PET scan. Our reviewer says that the enrollee meets the Medicare criteria for the requested PET scan. Our physician reviewer found while a direct laryngoscopy revealed no evidence of tumor, it is wise to evaluate the larynx via PET/CT following the examination results from March 26, 2019. If the area in question has resolved it can be dismissed, however if there has been an increase in activity a biopsy may be 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 PET scan have been met. Therefore, we decided that the Plan has to pre-approve a Positron Emission Tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forophthalmological services provided on October 15, 2019 by an out of network (OON) provider.You asked the Plan to pay forophthalmological services. You say that the doctor does not know which patients he will be seeing as he is assigned to the facility.The Plan denied your request. The Plan says the referring facility is out-of-network. The Plan says that no prior authorization was obtained for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We 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 forophthalmological services provided on October 15, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee scooter (E0118). You asked the Plan to pre-approve the knee scooter. You say that you will be having foot and ankle surgery and you will need the scooter to be able to get around your home and for everyday use as you are not supposed to walk or bear weight for 6 to 8 weeks. The Plan denied your request. The Plan says this request does not meet the medical necessity criteria. 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 knee scooter. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence in the submitted medical records that this durable medical equipment was ordered by the physician. There is no prescription from the treating physician or documentation in the medical records to support that this device is medically necessary and not just for the convenience of the patient. Therefore, this request for knee scooter is not medically reasonable and necessary per Medicare criteria 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 knee scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve the knee scooter (E0118).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a membership towards the 2019 wellness allowance benefit year.You asked the Plan to reimburse you for the membership. You say that rowing allows you to get a cardio workout with low impact. The Plan denied your request. The Plan says you submitted reimbursement for your 2019 wellness allowance for a non-qualifying health club.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules applyin this case.The Plan's rules for coverage of gym benefits have not been met because the "club" is non-qualifying health club.Therefore, we decided that the Plandoes not have to reimburse you for a membership towards the 2019 wellness allowance benefit year.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on July 16, 2018.You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was not received within the timely filing period.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the office visit was not filed until November 15, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to payfor an office visit (99214) provided on July 16, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Oxycodone/Acetaminophen tablet medication. You asked the Plan to pre-approve this medication. You say that this medication is medically necessary for the enrollee as he has been diagnosed with Rheumatoid Arthritis. The Plan denied your request. The Plan says this medication is not a covered benefit under the enrollee's contractual policy. The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Oxycodone/Acetaminophen tablet medication.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the brain (70551). You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied your request. The Plan says that rules for coverage have not been met. The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 MRI. Our reviewer says that the requested MRI is medically necessary. Our physician reviewer found in this case the patient has a history of both a possible anoxic injury (secondary to carbon monoxide exposure) and longstanding memory problems. It is standard in the evaluation of memory problems and memory impairments to have a patient undergo a neuroimaging study to evaluate for structural causes of cognitive impairment. 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the brain (70551).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveJardiance 25mg Tablets.You asked the Plan to pre-approveJardiance. You say that the medication is medically necessary.The Plan denied your request. The Plan says rules for coverage have not been met.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-approveJardiance 25mg Tablets.Benefits for Jardiancemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 have fallen, are having trouble ambulating, your quality of life depends on around the clock care due to your condition, and you have trouble performing any tasks to care for yourself. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that you require the intensity of an IRF stay with close physician or nursing supervision. While you may benefit from and participate in additional therapies of physical therapy and occupational therapy, you do not require this on an intensive rehabilitation therapy program level 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for catheter surgery (93656) and pay for self-administered drugs (A9270) provided from October 16, 2019 to October 17, 2019.
You asked the Plan to waive the coinsurance for catheter surgery and pay for self-administered drugs. You say that this should have been considered an inpatient stay. The Plan denied your request. The Plan says this processed 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 20% coinsurance for outpatient surgery. The rules also say that Medicare Part B generally does not pay for self-administered drugs.
You have been asked to pay a $3,982.67 coinsurance for catheter surgery. This is less than 20% of the allowed amount due to your out-of-pocket maximum. The record does not show you were admitted to inpatient status; therefore, this was an outpatient surgery. 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. Furthermore, 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 waive the coinsurance for catheter surgery (93656) and pay for self-administered drugs (A9270) provided from October 16, 2019 to October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on May 31, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on May 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve TheraSkin for
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan
denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee has a stage three pressure
ulcer. TheraSkin is considered investigative for all indications due to a lack of clinical evidence demonstrating
an impact on improved health outcomes. There are multiple other engineered skin substitutes which are
considered medically appropriate for treatment of lower extremity wounds which have not adequately
responded to at least one month of conventional therapy. TheraSkin is therefore not reasonable or medically
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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve TheraSkin for.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from August 29, 2019
to October 11, 2019. You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition did not require daily skilled services at an inpatient skilled nursing facility (SNF) level of care. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from August 29, 2019 to October 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation therapy.
You asked the Plan to pre-approve the endovenous ablation therapy. The Plan denied your request. The Plan
says the enrollee must receive care from in-network providers with the exception of emergency or urgent care
or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve
endovenous ablation therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetransurethral waterjet ablation (0421T).You asked the Plan to pre-approvetransurethral waterjet ablation. You say that the enrollee is an ideal candidate for this procedure.The Plan denied your request. The Plan says this is experimental and the enrollee is not in a clinical trial.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 transurethral waterjet ablation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found scientific data in the peer reviewed medical literature is very limited with regards to aquablation of the prostate. Long term evidence of its effectiveness and retreatement rates remains limited. Therefore it is considered experimental and cannot be considered medically necessaryat 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 transurethral waterjet ablation have not been met.Therefore, we decided that the Plan does not have to pre-approvetransurethral waterjet ablation (0421T).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 18, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for laboratory testing. You say that the referring physician was in-network with the
Plan. The Plan denied your request. The Plan says the denial of payment for these services is correct, because
this provider is out-of-network with the Plan and the referring physician is also out-of-network with the Plan.
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 medical services provided on May 18, 2019 by
an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee needs the level of care provided at a SNF. The Plan denied your request. The Plan says SNF services are not medically reasonable and necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, intact skin, and clear lungs. The enrollee received physical therapy, speech therapy, and occupational therapy. The enrollee was at a contact guard assist level with bed mobility and transfers. The enrollee required varying assist with activities of daily living. The enrollee tolerated a mechanical soft diet and thin liquids. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, but they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.