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

We decided that the Plan does not have to pre-approve Leuprolide Acetate (J9217).
You asked the Plan to pre-approve Leuprolide Acetate. You say that the requested medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 Leuprolide Acetate. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the enrollee had an elevated prostate-specific antigen (PSA) test, but has not yet had a biopsy to confirm prostate cancer. There are plans to treat the enrollee with a drug treatment called leuprolide acetate. This drug or mix of drugs is not supported in the National Comprehensive Cancer Network guidelines unless prostate cancer has been confirmed with a biopsy. The review has determined that the documentation does not support that the Leuprolide Acetate is medically reasonable and necessary for the enrollee at this time. The documentation does not support that the Leuprolide Acetate is safe and effective 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 Leuprolide Acetate have not been met. Therefore, we decided that the Plan does not have to pre-approve Leuprolide Acetate (J9217).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide routine transportation.
You asked the Plan to provide routine transportation. You say that you need transportation to appointments. The Plan denied your request. The Plan says you do not have a routine transportation benefit.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. The Plan no longer offers a routine transportation benefit. Based on this information, we decided that the Medicare rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to provide routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and the treatment of a knee fracture provided on August 19, 2019 by the out of network (OON) provider.
You asked the Plan to pay for the physician services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the service. The Plan also says the services were not urgent or emergent.
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 have to pay for the office visit and the treatment of a knee fracture provided on August 19, 2019 by the out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis eye drops.
You asked the Plan to pre-approve Restasis eye drops. You say that this should be covered. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.
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 Restasis eye drops.
Benefits for Restasis eye drops may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided October 7, 2019 to October 10, 2019.You asked the Plan to pay forthe acute inpatient hospital care. You say that you are requesting a reconsideration of the Plan's denial for payment of the inpatient services.The Plan denied your request. The Plan says that the inpatient hospital care provided was not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the Emergency Department (ED) on October 7, 2019 with complaints of abdominal and chest pain. Labs revealed normal cardiac biomarkers and an abnormal urinalysis suggestive of infection. He was treated with IV Ceftriaxone. He was then admitted and received further IV antibiotic therapy. Additionally, he was evaluated by Psychiatry.The member'scondition stabilized and improved, and he was discharged home when considered medically stable on October 10, 2019. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage ofacute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided October 7, 2019 to October 10, 2019. If the Plan does not agree with our decision,they can ask us to open acase 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided June 9 to June 12, 2019 by Out of Network (OON) Provider. You asked the Plan to pay for the post-stabilization inpatient care. You say that services were medically necessary.The Plan denied your request. The Plan says the out-of-network admission was not preauthorized.The Plan must follow Medicare rules. The rules say that plans do not have to pay for non-plan care except for emergencies, out-of-area urgently needed care, post-stabilization care and pre-approved care.  The record shows that the enrollee was stable for transfer as of June 9, 2019. Once the enrollee was deemed stable for transfer, the emergency ended. This means that the post-stabilization inpatient care was not provided in an emergency. The inpatient care also did not involve out-of-area urgent care services and it was not pre-approved.Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided June 9 to June 12, 2019 by Out of Network Provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on April 4, 2019.You asked the Plan to pay forthe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicarecoverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary and conducted a face-to-face assessment.Therefore, we decided that the Plan doesnot have to pay fora lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on April 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab services provided to the enrollee on September 25, 2019 and billed under code G0480.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare billing criteria were not met.The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes.Therefore, we decided that the Plan does not have to pay forlab services provided to the enrollee on September 25, 2019 and billed under code G0480.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit for the enrollee.You asked the Plan to pre-approve Procrit. You say that this is medically necessary.The Plan denied your request. The Plan says that there was no evidence that the enrollee has tried and failed a trial of Retacrit.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 Procrit. Our reviewer says that Procrit is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed Retacrit (Epoetin alfa-epbx) or that it would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Procrit.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Procrit have not been met.Therefore, we decided that the Plan does not have to pre-approve Procrit for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tramadol HCL for the enrollee.You asked the Plan to pre-approve this drug. You say that the enrollee has been doing well on this treatment plan.The Plan denied your request. The Plan says that this is not covered under Part B.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-approveTramadol HCL for the enrollee.Benefits for this drug may be available underMedicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 93010) provided on September 8, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this was a duplicate claim.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The services in question were billed on a claim that is considered to be a duplicate of a claim that was previously paid by the plan for the same date of service. 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 pay for the services (CPT 93010) provided on September 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora hearing aid purchased out of network. You asked the Plan to pay forhearing aids out of network. You say that you think this hearing aid should be covered by the Plan.The Plan denied your request. The Plan says hearing aids are only covered when purchased from the designated provider. Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only from a designated provided. You did not purchase the hearing aid fromthe designated provider. Therefore, we decided that the Plan does not have to pay fora hearing aid purchased out of network on September 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysicians services provided on November 21, 2019 by an out of network (OON) provider.You asked the Plan to pay forphysician services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says 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 forphysicians services provided on November 21, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient hospital services provided on November 4, 2019 by an out of network (OON) provider.You asked the Plan to pay foroutpatient hospital services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says 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 foroutpatient hospital services provided on November 4, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral exams (D0150) surgical extractions (D7210) provided March 18, 2019 to September 10, 2019.You asked the Plan to pay for the dental services. You say that please review as your health issues contributed to bone loss and is the is cause for the extractions.The Plan denied your request. The Plan says these services are not covered under the plan benefits.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay for comprehensive oral exams (D0150) surgical extractions (D7210) provided March 18, 2019 to September 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for short chain fatty acid stool assessment provided to the enrollee on January 15, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says this testing is not covered by Medicare.
The Plan follows Medicare rules. The rules explicitly say that screening tests, except for the few tests listed above, are not covered. The test at issue in this appeal, this service, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for short chain fatty acid stool assessment provided to the enrollee on January 15, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction 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 this is considered experimental and investigational.
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 device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on September 19, 2019
by an out of network (OON) provider.
You asked the Plan to pay for the OON psychotherapy visits. You say that the enrollee is being seen at the
request of the facility. The provider is enrolled in Medicare and the plan should pay for the services. The Plan
denied your request. The Plan says there are network providers who can provide this service and the provider
failed to request authorization to see the patient 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 the psychotherapy services provided on September
19, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea full body bone scan.You asked the Plan to pre-approvethe bone scan. The Plan denied yourrequest. The Plan says there is no information provided to support the need for this study.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 bone scan. Our reviewer says that  Our physician reviewer found We looked at the file, and Medicare rules. There are insufficient records to show the testing is needed to determine a diagnosis or illness present. Based on this information, we decided that Medicare rules for coverage of the bone scan have not been met. Therefore, we decided that the Plan does not have to pre-approvea full body bone scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for immediate upper denture (D5130) extraction (D7140) surgical extraction (D7210) provided October 21, 2019 to November 12, 2019.
You asked the Plan to pay for the dental services. You say that the records should support the necessity of the services in dispute. The Plan denied your request. The Plan says the requested services are not covered under the plan's benefit package.
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 immediate upper denture (D5130) extraction (D7140) surgical extraction (D7210) provided October 21, 2019 to November 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on June 21, 2019 and billed under codes G0483 and 80307.You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare billing criteria were not met.The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on June 21, 2019 and billed under codes G0483 and 80307.