Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a behavioral health facility for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says there was no evidence provided that treatment could not be provided in a less restrictive outpatient level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee does not meet the criteria for acute inpatient mental health treatment as this enrollee was not shown to be a danger to himself or others but was without agitation or aggression without perceptual disturbance including auditory or visual hallucinations. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a behavioral health facility for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 8 additional extractions provided on December 16, 2019.
You asked the Plan to pay for the extractions. You say that the Plan approved the denture and extractions. You
also say that you cannot afford to pay for this. The Plan denied your request. The Plan says the frequency
limitation has been exceeded for this service.
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, extractions are limited to two
procedures per calendar year. The record shows that you received one extraction on September 27, 2019, and 9
extractions on December 16, 2019, one of which was covered, and your extractions benefit was then exhausted.
Therefore, we decided that the Plan does not have to pay for the 8 additional extractions provided on December
16, 2019.
Your complaint about your dissatisfaction with the Plan is not a valid appeal for medical coverage. This part of
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a
decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copays forthe physical therapy services you received from September 5, 2019, to October 1, 2019.You asked the Plan to waive the copays forthe physical therapy services. You say that you did not go to a hospital for physical therapy.The Plan denied your request. The Plan says the copays were 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 $40 copay for physical therapy in an outpatient hospital facility. We looked at the file and the rules. Although you may not have gone to an actual hospital building, the facility you received services from is affiliated with a hospital. This means that you received services at an outpatient hospital facility. You have been asked to pay a $40 copay for eachphysical therapy service. The servicesfallwithin the outpatient rehab services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copays forthe physical therapy services you received from September 5, 2019, to October 1, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve for an inpatient hospital admission for a total knee replacement.
You asked the Plan to pre-approve for acute inpatient hospital care. You say that inpatient level care is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 pre-approve for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the procedure can be performed in an outpatient setting. The record does not show that the patient's necessary hospital 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 of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve for an inpatient hospital admission for a total knee replacement.
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 July 17, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 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 July
17, 2019.
Appeal type: Lab
Decision: Unfavorable

You asked the Plan to pay for drug tests. You say that you have submitted a valid laboratory requisition form.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted did not include a valid physician order, lab requisition, or medical records stating exactly which tests were to be performed.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab testing billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met.Therefore, we decided that the Plan does not have to pay for drug testing provided by provider on October 7, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten additional physical therapy sessions for the enrollee.
You asked the Plan to pre-approve the sessions. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical documentation does not show that the ongoing skills of a physical therapist are needed.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 sessions. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested 10 PT sessions are generally not accepted as specific and effective therapy for the enrollee's condition. The enrollee has had prior therapy visits and the documentation does not reveal evidence of significant objective functional improvement from this therapy. The enrollee's current non weight bearing status limits significant need for skilled therapies at this time. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.
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 sessions have not been met. Therefore, we decided that the Plan does not have to pre-approve ten additional physical therapy sessions for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 17, 2019.
You asked the Plan to pay for the physician's services. 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, dialysis while
temporarily out of the plan's service area 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 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 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 physician's services provided on October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT)(77523).
You asked the Plan to pre-approve PBRT. You say that this is medically necessary. The Plan denied your request. The Plan says this has not been shown to be more effective that other types of radiation therapy.
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 PBRT. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry. The enrollee is not currently enrolled in a clinical trial. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT)(77523).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services provided to enrollee on November 26, 2019.You asked the Plan to pay for the services provided. You say that the test measure and monitor serum and ATV levels during therapy.The Plan denied your request. The Plan says the testing is experimental/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 pay for the services provided. Our physician reviewer found that  based on the records provided, the provided testing was not medically reasonable and necessary for the enrollee and would be considered experimental/investigational.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 services provided have not been met.Therefore, we decided that the Plan does not have to pay for the testing services provided to enrollee on November 26, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued physical therapy (PT) services.You asked the Plan to pre-approve these services. You say that you are still having neck and back pain.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the submitted records show that you have received a home exercise program for continued self-maintenance. PT is generally accepted as specific and effective therapy for your condition; however, the records do not support that you require the unique skills of a professional therapist. The prior PT has not provide sustained or significant relief. Your continued needs can be addressed by the home exercise program. The requested PT is not reasonable or medically necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approve continued physical therapy (PT) services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 11, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for laboratory testing. You say that you cannot turn away specimens for testing as
the results are crucial to the enrollee's care with the ordering physician. The Plan denied your request. The Plan
says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and
the ordering 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 December 11,
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran outpatient hospital visit provided on April 22, 2019.You asked the Plan to waive the copayment foroutpatient hospital visit. You say that the enrollee was sent for a specialist visit and not as an outpatient procedure.The Plan denied your request. The Plan says the copayment amount the enrollee is being charged is correct.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay $300 copayment for outpatient hospital visit.The enrollee has been asked to pay the allowed amount of $270.81, which is less than the $300 copayment for outpatient hospital visit. Outpatient hospital visit falls within the Outpatient Hospital Services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran outpatient hospital visit provided by on April 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve the Prolia. You say that oral bisphosphonates are contraindicated due to
member's extensive GI history and IV bisphosphonate contraindicated due to diabetes and decreased renal
function.
The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.
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 the Prolia. Our reviewer says that the
member has not tried and failed a trial of oral bisphosphonate drug and zoledronic acid. 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 the Prolia have not been met. Therefore, we decided that the Plan does not have
to pre-approve Prolia (J0897).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the daratumumab injection,
dexamethosone sodium phosphate injection, diphenhydramine HCl injection and chemotherapy administration
provided on September 27, 2019.
You asked the Plan to waive the coinsurance for the injections and chemotherapy administration. You say that
you cannot afford to pay the cost share. The Plan denied your request. The Plan says cost share is a contractual
obligation under the plan and cannot be waived.
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 you must pay a 20%
coinsurance for each Medicare-covered Part B drug and each Medicare-covered chemotherapy drug and the
administration of that drug.
You have been asked to pay a 20% coinsurance for the injections and chemotherapy administration. The
injections fall within the Medicare-covered Part B drug and the chemotherapy administration falls within the
Medicare-covered chemotherapy drug and the administration of that drug benefit category. This means that you
have been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does
not have to waive the coinsurance for the daratumumab injection, dexamethosone sodium phosphate injection,
diphenhydramine HCl injection and chemotherapy administration provided on September 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite - one surface, anterior (D2330) provided on December 12, 2019.
You asked the Plan to pay for the resin-based composite. You say that on December 5, 2019 the Plan gave you approval for all of your fillings. The Plan denied your request. The Plan says you exceeded the number of allowed filling for the time period stated in your EOC.
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, restorations are limited to two procedures per calendar year. The record shows that you received 3 resin-based composites on December 12, 2019, two of which were covered, and your restorations benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the resin-based composite - one surface, anterior (D2330) provided on December 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for medical services to be provided by an out
of network (OON) provider.
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services can be provided by a network
provider.
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 referral for medical services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on December 23, 2019.
You asked the Plan to pay for the orthosis. 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 Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on December 23, 2019.