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

We decided that the Plan has to pre-approvePrivigen for the enrollee.You asked the Plan to pre-approvePrivigen. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that that Privigen is not FDA approved for limbic encephalitis.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Privigen. Our reviewer says that Privigen is medically reasonable and necessary for the enrollee in this case. Literature suppliedin this medical record supports the use of Privigen in this case. This would be a continuation with response from inpatient treatment in October of 2020. Our physician reviewer found that the enrollee's condition meets criteria for coverage of Privigen.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Privigen have been met.Therefore, we decided that the Plan has to pre-approvePrivigen for the enrollee.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the OON medical services. You say that you have been diagnosed with cancer and have found this provider to provide the surgery on your bladder to assist with the needed care for your diagnosis.The Plan denied your request. The Plan says there is no medical showing why the enrollee cannot get the office consultation services from a provider with the Plan 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 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 the medical services 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 waive the cost share charged for physician services provided on January 14, 2020.
You asked the Plan to waive this service. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says this cost share was applied per the Plan contract agreement
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 cost share for physician services and injection services. 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 cost share charged for physician services provided on January 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on December 20, 2018.
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says they were unable to make a determination within the allotted time frame.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided on December 20, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on July 1, 2020.

You asked the Plan to pay for the periodontal maintenance. You say that the dentist called this service a cleaning. You also say that the Plan is liable for 2 cleanings per year. The Plan denied your request. The Plan says this service is not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance provided on July 1, 2020.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for an X-ray study of swallowing function. We decided that the Plan does not have to reduce the cost-sharing charges for an X-ray study of swallowing function to the amount you requested.
You asked the Plan to reduce the cost-sharing charges for an X-ray study of swallowing function. You say that the Plan is applying a higher copayment for the service. The Plan says that the claims were processed correctly and you are being charged the correct amount.
We decided that the Plan has to reduce the cost-sharing charges for an X-ray study of swallowing function from $130 to $14.
The Plan contract says that you must pay a $14 copayment for X-rays. Therefore, you cannot be asked to pay more than a $14 copayment. We decided that the Plan has to reduce the cost-sharing charges for an X-ray study of swallowing function from $130 to $14.
We also decided that the Plan does not have to reduce the cost-sharing charges for an X-ray study of swallowing function to the amount you requested.
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 $14 copayment for each X-ray. Therefore, we decided that the Plan does not have to reduce the cost-sharing charges for an X-ray study of swallowing function to the amount you requested.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay foran x-ray provided on August 21, 2020 by an out of network (OON) provider.You asked the Plan to pay foran x-ray. 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.Medicarerules 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 foran x-ray provided on August 21, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health care.You asked the Plan to pre-approvehomehealth care. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the records provided do not indicate that you are confined to your home.The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care services to be covered. The file does not show that you are homebound.Therefore, we decided that the Plan does not have to pre-approvehome health care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEntresto.You asked the Plan to pre-approveEntresto. The Plan denied your request. The Plan says this medication is an outpatient prescription drug and is not covered under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generallydoes 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-approveEntresto.Benefits for Entrestomay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the primary closure of a sinus perforation (D7216) and the therapeutic parenteral drugs, two or more administrations (D9216) provided on January 17 2020.

You asked the Plan to pay for the primary closure of a sinus perforation and the therapeutic parenteral drugs. You say that an attempt was made to removed tooth # 3 non-surgically, but the tooth fractured. You also say that the services were necessary. The Plan denied your request. The Plan says the primary closure of a sinus perforation is not listed as a covered service. The Plan says that therapeutic parenteral drug 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. Additionally, the Evidence of Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to pay for the primary closure of a sinus perforation (D7216) and the therapeutic parenteral drugs, two or more administrations (D9216) provided on January 17 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D0220, D0140, D5110, and D7140) provided by an out-of-network provider.

You asked the Plan to pay for dental services. You say that you were unaware you had to go in-network for services rendered.The Plan denied your request. The Plan says you are responsible for 100% of services rendered with an out of network provider

.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

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. Specifically, you received this service out-of-network.Therefore, we decided that the Plan does not have to pay for dental services (D0220, D0140, D5110, and D7140) provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is appropriate for inpatient
rehabilitation, and would do well. The Plan denied your request. The Plan says the IRF admission is not
medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described 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 was
admitted for infection of the right foot with sepsis. Our reviewer found that the enrollee does not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. The medical record supports a need for physical and occupational therapy, but
it does not support a need for an intensive rehabilitation therapy program. Our physician reviewer also found
that 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs therapy because she is very weak, and cannot do anything on her own. You also say that you want the enrollee to become strong enough to become independent again. The Plan denied your request. The Plan says acute inpatient rehab is not medically necessary for the enrollee. The Plan also says that the enrollee can be safely treated at a less intensive 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 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. Our reviewer found that the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy, but it does not support a need for an intensive rehabilitation therapy program. Our physician reviewer also found that 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forsubsequent hospital care (99232) provided on February 11, 2020 by an out of network (OON) provider.You asked the Plan to pay forsubsequent hospital care. You say that the doctor should not be penalized because the facility staff did not get prior authorization.The Plan denied your request. The Plan says services with non-contracted providers must be prior authorized.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 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 haveto pay forsubsequent hospital care (99232) provided on February 11, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.You asked the Planto pre-approvethis service. You say that SNF services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. 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 this service. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the medical records do not show the enrollee requires daily skilled nursing or daily skilled therapy services at a SNF level of care. Medicare coverage criteria are not met.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have topre-approveskilled nursing facility (SNF) services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea CT scan of the soft tissue of the neck (70490), a CT scan of the thorax (71250), and a CT scan of the abdomen and pelvis (74176).You asked the Plan to pre-approvethe CT scans. You say that the requested CT scans are medically necessary.The Plan denied your request. The Plan says therequested CT scans are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT 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 the CT scans. Our reviewer says that the requested CT scans are not medically necessary. Our physician reviewer found the enrollee is with a diagnosis of diffuse large B cell lymphoma (DLBCL). Per NCCN guidelines for DLBCL, follow-up CT scans are necessary when clinically indicated. In this case, the notes reflect the enrollee is fearful; however, no clinical indication for any of the requested CT scans has been demonstrated in the records provided.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 CT scans have not been met.Therefore, we decided that the Plan does not have to pre-approvea CT scan of the soft tissue of the neck (70490), a CT scan of the thorax (71250), and a CT scan of the abdomen and pelvis (74176).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to the outpatient rehabilitation program.

You asked the Plan to pre-approve admission to the outpatient rehabilitation program. You say that the requested admission to the outpatient rehabilitation program is medically necessary. The Plan denied your request. The Plan says the requested admission to the Institute outpatient rehabilitation program does not meet the Plan's admission 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 admission to the outpatient rehabilitation program. Our reviewer says that the requested admission to the outpatient rehabilitation program does not meet the Plan's admission criteria. Our physician reviewer found the documentation does not support that the enrollee meets the criteria for the requested program. The enrollee is ambulating 1100ft with a SPC and close standby assist and transfers with standby assist, dynamic standing tasks required supervision, and standby to supervision with all activities of daily living as of 12/2/20. He continues to to have severe dysphagia as of 12/2/20. The enrollee no longer requires all three therapy modalities administered concurrently in an intensive setting and he still requires individual part B therapy modalities therefore the requested day institute therapy program is not 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 admission to the outpatient rehabilitation program have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to the outpatient rehabilitation program.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for paravertebral facet joint injection (64490 x2, 64491 x2, 64492 x2) provided July 20, 2020.
You asked the Plan to pay for the injection service's. You say that the records should support the necessity of the service in dispute. The Plan denied your request. The Plan says CPT 64490, 64491,64492 has an MUE value of 1, provider billed 2 units for each procedure code.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT codes 64490, 64491 and 64492 is 1. You billed 2 units of these codes, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the injection service's have not been met. Therefore, we decided that the Plan does not have to pay for paravertebral facet joint injection (64490 x2, 64491 x2, 64492 x2) provided July 20, 2020.