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

We decided that the Plan does not have to pre-approveProlia 60mg/ml syringe (J0897).You asked the Plan to pre-approveProlia 60mg/ml syringe. You say that the medication is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met.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 Prolia 60mg/ml syringe. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that Zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia 60mg/ml syringe have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia 60mg/ml syringe (J0897).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy rendered to you from September 10, 2019 to October 3, 2019. You asked the Plan to waive the coinsurance for these services. You say that you are on a fixed income. The Plan denied your request. The Plan says the coinsurance was applied correctly. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for each Medicare-covered Part B drug. Review of the file shows that you received chemotherapy from September 10, 2019 to October 3, 2019. You have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare-covered Part B drug benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the chemotherapy rendered to you from September 10, 2019 to October 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the office visit, the somatosensory testing, and the arterial study provided on October 18, 2019.You asked the Plan to waive the cost share for the office visit, the somatosensory testing, and the arterial study. You say that you say you do not agree with the cost-share. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.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 $10 copayment for services obtained from an in-network primary care provider, 20% coinsurance for in-network Medicare-covered non-radiological diagnostic services, and 20% coinsurance for each in-network Medicare-covered radiological diagnostic service, not including x-ray, performed in a physician's office or free-standing radiology facility. You have been asked to pay a total of $58.89 for the office visit, the somatosensory testing, and the arterial study. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The somatosensory testing and the arterial study falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. See chart below. 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 cost share for the office visit, the somatosensory testing, and the arterial study provided on October 18, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CPAP supplies provided on August 6, 2019. You asked the Plan to pay for the CPAP supplies. You say that the Plan should pay this claim. The Plan denied your request. The Plan says there is no physician order for the supplies. 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 shows that the Plan made several attempts to obtain the physician order for the items at issue in this appeal. The record does not contain a valid physician order for the supplies provided in this case. The physician order did not contain these supplies. Therefore, we decided that the Plan does not have to pay for the CPAP supplies provided on August 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 3, 2020 to January 6, 2020 by an out of network (OON) provider.You asked the Plan to pay for physician services. You say that you would like this appeal reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained.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 physician services provided on January 3, 2020 to January 6, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmology services provided on December 14, 2018 by an out of network (OON) provider.
You asked the Plan to pay for the ophthalmology services. You say that you do not need an authorization for the services because you are contracted. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 ophthalmology services provided on December 14, 2018 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a duplex scan and varicose vein treatment to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a duplex scan and varicose vein treatment. You say that these services are a continuation of care. The Plan denied your request. The Plan says these services could be provided 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 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 items/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 a duplex scan and varicose vein treatment 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 pay for the medical services provided to you by an out-of-network provider on January 3, 2020.
You asked the Plan to pay for the services. You say that this provider was in-network in 2019. The Plan denied your request. The Plan says the services were not 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 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 you by an out-of-network provider on January 3, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided from November 26, 2019 to November 28, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you were an admitted as an inpatient and not under observation The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $100 copayment for each Medicare-covered emergency room visit. You have been asked to pay a $100 copayment for the emergency room visit. The emergency room visit falls within the "Outpatient hospital services" benefit category. The medical record shows that you were admitted to observation.
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 the emergency room visit provided from November 26, 2019 to November 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Dental services (D0274, D1110) provided out-of-network on September 3, 2019.
You asked the Plan to pay for the out-of-network dental services. You say that the services were necessary and should be covered. The Plan denied your request. The Plan says dental services received out-of-network are not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for Dental services (D0274, D1110) provided out-of-network on September 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an Automated External Defibrillator (K0606) provided on November 6, 2019.
You asked the Plan to waive the coinsurance for the defibrillator. You say that the coinsurance should be waived. The Plan denied your request. The Plan says the correct cost sharing was applied.
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 Durable Medical Equipment. You have been asked to pay a 20% coinsurance for the defibrillator. The defibrillator falls within the Durable Medical Equipment 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 an Automated External Defibrillator (K0606) provided on November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Inflectra.
You asked the Plan to pre-approve Inflectra. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says there is no evidence of failure of Infliximab therapy despite
increased dosing or frequency of dose.
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 Inflectra. Our reviewer says that the
documentation does not support that the requested drug, Inflectra is medically reasonable or necessary. Our
physician reviewer found the enrollee is noted to have ulcerative colitis, for which she takes Remicade. In both
October 2018 and the August 2019, the enrollee was noted to have recurrence of symptoms prior to her next
Remicade dose. Therefore, in August 2019 there was a plan to increase the frequency of Remicade dosing from
every eight weeks to every four weeks. The response to this change is not documented. Without ongoing
documentation of ineffectiveness, despite an increase in the frequency of Remicade, the request for Inflectra is
not shown to be medically necessary or reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Inflectra have not been met. Therefore, we decided that the Plan does not have
to pre-approve Inflectra.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a 140mg/ml Aimovig Autoinjector.
You asked the Plan to pre-approve the Aimovig Autoinjector. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says this drug is intended for selfadministration
and not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 a 140mg/ml Aimovig
Autoinjector.
Benefits for the Aimovig Autoinjector 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a combination sit to stand frame/table system.
You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that Medicare does not consider this equipment reasonable or necessary.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a combination sit to stand frame/table system.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 13 additional home health occupational therapy visits.
You asked the Plan to pre-approve additional home health occupational therapy visits. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says [Enter plan denial rationale, e.g. "...rules for SNF care have not been met."]
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 additional home health occupational therapy visits. Our reviewer says that the documentation does not support that the requested home health services are medically reasonable or necessary. Our physician reviewer found the enrollee has a history of memory deficits and a prior stroke. The enrollee requires minimal assistance for transfers. The enrollee required medication management and supervision given ongoing safety concerns. The documentation does not support that the enrollee meets criteria for the requested home health occupational services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional home health occupational therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 13 additional home health occupational therapy visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) coverage after April 16, 2020.
You asked the Plan to pre-approve continued SNF coverage. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 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 continued SNF coverage. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the SNF after a fall and has rhabdomyolysis. The enrollee received oral medications. The enrollee had stable vital signs. The documentation does not support that the enrollee requires the specialized skill, knowledge and judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that the enrollee requires skilled nursing or skilled therapy services on a daily basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued SNF coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) coverage after April 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on October 15, 2019.
You asked the Plan to pay for the 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 Medicare coverage 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 does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on October 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a Nebulizer (E0570) obtained November 26, 2019 from the provider.
You asked the Plan to pay for the nebulizer. You say that the Nebulizer is medically necessary. The Plan denied your request. The Plan says there were network providers available that could provide the item in question.
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 a Nebulizer (E0570) obtained on November 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for unlisted Procedure dentoalveolar structures (41899) anesthesia for intraoral procedures, including biopsy (00170) sectioning of a fixed partial denture (D9120) graft bone nasal/maxillary/malar areas (21210) provided November 1, 2018.
You asked the Plan to pay for the dental services. You say that these dental services are a result of an injury to the face and feel that they should be covered. The Plan denied your request. The Plan says these services are not covered under the plan benefits.
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 unlisted Procedure dentoalveolar structures (41899) anesthesia for intraoral procedures, including biopsy (00170) sectioning of a fixed partial denture (D9120) graft bone nasal/maxillary/malar areas (21210) provided November 1, 2018.