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

We decided that the Plan does not have to pre-approvea 4Kscore Test Algorithm.You asked the Plan to pre-approvea 4Kscore Test Algorithm. You say that the requested 4Kscore test is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria forthe requested 4Kscore test.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 a 4Kscore Test Algorithm. Our reviewer says that the enrollee does not meet criteria for the requested 4Kscore test. Our physician reviewer found the enrollee is with prostate cancer. The enrollee had 2 separate 4Kscores in 2018 and 2019. The enrollee would like further 4kscore testing rather than biopsy. Persistent and significant increase in PSA should be encouraged to undergo biopsy. The enrollee does not meet Medicarecriteria in this case as the enrollee has persistent PSA elevation with abnormal 4kscore previously. Persistent and significant increase in PSA should be encouraged to undergo biopsy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a 4Kscore Test Algorithm have not been met.Therefore, we decided that the Plan does not have to pre-approvea 4Kscore Test Algorithm.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approvecontinued skilled nursing facility (SNF) services after June 20, 2020.You asked the Plan to pre-approveSNF care. You say that the requested continuation of SNF care is medically necessary.The Plan denied your request. The Plan says that the enrollee does not meet criteria for continued SNF care.The Plan must follow Medicare Rules. The rules say that Medicareplans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal.We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before June 20, 2020. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued.Therefore, we decided that the Plan has to pre-approvecontinued skilled nursing facility (SNF) services after June 20, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Gel-One.You asked the Plan to pre-approve Gel-One. You say that you are appealing with supporting documents.The Plan denied your request. The Plan says the denial of authorization for Gel-One is correct, because the Plan requires a trial of Monovisc and Orthovisc before it will approve Gel-One.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 Gel-One. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Gel-One. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drugs of Monovisc and Orthovisc. The documentation does not support that Monovisc and Orthovisc would likely be less effective and/or 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 Gel-One have not been met.Therefore, we decided that the Plan does not have to pre-approve use of Gel-One.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested SNF admission. 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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with dementia, muscular dystrophy, arthritis, trouble swallowing, and high blood pressure. The enrollee has a PEG tube for maintenance of nutrition and uses a walker to ambulate. MMSE is 14 (on 6/10/2020). The member is confused and warrants minimal assist/supervision for all aspects of care. Medications include HCTZ. The enrollee is now mostly minimal assist/supervision for all care. The enrollee has no complex wound care needs, or IV medication requirements. There are no nursing or therapy needs that are skilled, and warranting a SNF as opposed to a lesser level of care. The enrollee's vital signs are stable; the enrollee is tolerating an oral diet; has no significant bowel or bladder deficits; and pain is controlled. 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 a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 77062) provided on December 11, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered
service.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee
Schedule indicates that the code in question is not valid for Medicare purposes.
We looked at the file and Medicare rules. Procedure code 77062 is assigned a status indicator of "I" under the
Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another
code for reporting of, and payment for, these services. 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 77062) provided on December 11, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you collapsed at a bank and an ambulance was called for you. You say that you refused to go to the hospital and the paramedics instead provided a wellness check. They tested your blood sugar levels, monitored your heart rhythms and took your temperature. You stated that they questioned you and determined that you were dehydrated. You say that when they thought you were stable and no longer in jeopardy of fainting they allowed you to leave. You stated that you received more medical care from the ambulance responders than when you go to the hospital for a lot cheaper than the hospital would have charged. You say that you received good and needed medical care and asked the Plan to cover the charges. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 5, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy and coinsurance for Part B drugs provided by a participating hospital on June 10, 2019. You asked the Plan to waive the copayment and coinsurance for a diagnostic colonoscopy and Part B drugs. You say that you never had to pay for these services before you switched to this health plan. You say that you are afraid to go to the doctor's because you will get a bill. The Plan denied your request. The Plan says the correct coinsurance and copayment has been 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 Medicare part B prescription drugs/in-network and a $300 copayment for outpatient surgery/in-network. You have been asked to pay a 20% coinsurance of the allowed amount for Part B drugs and a $300 copayment for a diagnostic colonoscopy. The total allowed amount is $26.18. The total coinsurance that you are being asked to pay is $5.24 ($26.18 x 20% = $5.24). The total amount you are being asked to pay is $305.24 ($300 + $5.24 = $305.24). A diagnostic colonoscopy falls within the outpatient surgery/in-network benefit category and Part B drugs falls within the Medicare part B prescription drugs/in-network 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 copayment and coinsurance for a diagnostic colonoscopy and Part B drugs provided by a participating provider on June 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says LTACH admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the injection (67028) and coinsurance for bevacizumab (J9035) provided on February 20, 2020. You asked the Plan to waive the copayment for the injection (67028) and coinsurance for the bevacizumab. You say that you would like reconsideration because the cost of these injections has been less in the past. The Plan denied your request. The Plan says you are responsible for 20% of the plan-allowed amount for Medicare Part-B covered drugs. 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 $35 copayment for each specialist visit and a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay $66.74 for the bevacizumab injection. The copay for specialist visits is $35. The allowed amount for bevacizumab is $158.70. 20% of $158.70 is $31.74. $35+$31.74 is $66.74. 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 injection (67028) and coinsurance for bevacizumab (J9035) provided on February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient hospital services received
on March 6, 2020.
You asked the Plan to waive the coinsurance for the outpatient hospital services. You say that you would like
the plan to reconsider their decision. The Plan denied your request. The Plan says the services received were
processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Medicare Part B drugs.
You have been asked to pay 20% coinsurance for the outpatient hospital services. The outpatient hospital
services fall within the Medicare Part B drugs 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 outpatient hospital services received on March 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve addition, endoskeletal system, below knee, flexible protective outer surface covering system.
You asked the Plan to pre-approve a protective outer surface covering system (L5962). You say that you need a specialized cover for your prosthetic. The Plan denied your request. The Plan says the information received does not show you would be exposed to harsh environmental situations.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The record does not show why the protective cover that is approved would not be sufficient protection. Based on this information, we decided that Medicare rules for coverage of protective outer surface covering system (L5962) have not been met. Therefore, we decided that the Plan does not have to pre-approve addition, endoskeletal system, below knee, flexible protective outer surface covering system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Chimeric antigen receptor T-cell (CAR-T) therapy. 
 
You asked the Plan to pre-approve CAR-T therapy. You say that this should be covered by the Plan. The Plan denied your request. The Plan says coverage of this service is the responsibility of Original Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare contractors will pay for covered clinical trial services furnished to beneficiaries enrolled in managed care plans. 
 
We looked at the file and Medicare rules. The records show that the requested service is being provided as part of a clinical trial. Coverage of clinical trial services is the responsibility of Original Medicare. Based on this information, we decided that Medicare rules for coverage of CAR-T therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve Chimeric antigen receptor T-cell (CAR-T) therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and panoramic x-ray provided on June 19, 2019 by an OON provider.You asked the Plan to pay for the problem focused limited oral evaluation and panoramic x-ray. You say that prior to the services being rendered, you spoke with a Plan representative and were advised that these services would be covered.The Plan denied your request. The Plan says the treating provider is OON. The Plan also says that there are network providers available within the time and distance standard of Medicare.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 covered when they are received OON.Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation and panoramic x-ray provided on June 19, 2019 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic and retainer crown.
You asked the Plan to pre-approve the pontic and retainer crown. You say that you are on a fixed income and cannot pay for your dental expenses. You also say that you are unable to eat regular food because you have no back teeth on either side of your lower jaw. The Plan denied your request. The Plan says these services are not covered by your plan.
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 pre-approve a pontic and retainer crown.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on January 4, 2020. You asked the Plan to pay for the comprehensive oral evaluation. You say that you have never seen a periodontist in your life. You also say that you were referred by your primary dentist. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan. 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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The records show that you received a comprehensive oral evaluation on November 08, 2018 and your comprehensive oral evaluation benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on January 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for wellness visit. You say that you could not find an in-network provider for this service. 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 this service could have been obtained within 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 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 January 30, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 28, 2019. You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you 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 August 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 20, 2020.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says services from non-participating providers are not covered under open access unless pre-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 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 subsequent nursing facility care provided on January 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. The Plan denied your request. The Plan says that your request exceeds the benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of thirty (30) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.