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

We decided that the Plan does not have to pre-approve Genicular nerve block (CPT Code 64454).
You asked the Plan to pre-approve the services. You say that the insurance company never contacted you to inform of dropping the service. You state you should have been informed prior to renewal, because the same procedure has been done before and approved. The Plan denied your request. The Plan says medical studies have not proven that the service(s) or procedure(s) is helpful for treatment of your health problem.
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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Genicular nerve block remains experimental for the treatment of knee pain. More research is needed to show safety and efficacy. 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 have not been met. Therefore, we decided that the Plan does not have to pre-approve Genicular nerve block (CPT Code 64454).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH 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 thecase 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 admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for heart failure.  The enrollee was intubated/ventilated, underwent heart valve surgery and eventually received a tracheotomy.  The enrollee has been tolerating ventilator weaning, but continues to show evidence of fluid overload requiring diuresis.  There is no evidence that the enrollee requires services that are not currently available.  As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.  The enrollee can remain at the current ACH until such time no acute services are required.  The enrollee can then be transferred/discharged to a lower level of care for anyongoing long term care needs.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-approvelong term acute care hospital (LTACH) services
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forComputed Tomography (CT) of the head (70450) provided September 1, 2020.You asked the Plan to waive the copayment forthe CT scan. You say that the copayment 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 $150 copayment for Diagnostic Radiology. You have been asked to pay the Medicare allowable amount of $117.39 for the CT scan. The CT scan falls within the Diagnostic Radiology benefit category. The allowable amount is less than the $150 listed in the Evidence of Coverage. This means that youhave 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 forComputed Tomography (CT) of the head (70450) provided September 1, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePred Forte eye drops for the enrollee.You asked the Plan to pre-approvethis drug. You say that this is medically necessary.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-approvePred Forte eye drops for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan thatadministers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora Medicare Part B drug injection provided on July 16, 2020.You asked the Plan to waive the coinsurance fora Medicare Part B drug injection. You say that you feel that the charges are too high.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug injection on July 16, 2020. The allowed amount is $4,029.20 and 20% of that is $805.84. You have been asked to pay the total coinsurance amount of $805.84 for a Medicare Part B drug injection. A Medicare Part B drug injection falls within the Medicare Part B prescription 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 fora Medicare Part B drug injection provided on July 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora partial denture (D5214) received on September 3, 2020.You asked the Plan to pay fora partial denture. You say that your denture was destroyed and you do not have the money to replace it.The Plan denied your request. The Plan says rules for payment have not been met.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. The Plan covers a partial denture every 5 years. We looked at the case file and Medicare rules. The record documents that you previously received a partial denture on July 9, 2019. This date of service is fewer than 5 years ago. Based on this information, we decided that the Plan's rules for coverage of a partial denturehave not been met.Therefore, we decided that the Plan does not have to pay fora partial denture (D5214) received on September 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuous glucose monitor (CGM) and supplies.You asked the Plan to pre-approvea CGM and supplies. You say that this is medically necessary.The Plan denied your request. The Plan says that this is not covered for your condition.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrolleeswith diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met.Therefore, we decided that the Plan does not have to pre-approvea continuous glucose monitor (CGM) and supplies.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiotherapy.
You asked the Plan to pre-approve proton beam radiotherapy. You say that the requested proton beam
radiotherapy is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet
criteria for the requested proton beam radiotherapy.
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 proton beam radiotherapy. Our
reviewer says that the enrollee does not meet criteria for the requested proton beam radiotherapy. Our physician
reviewer found to date, there are no compelling data to suggest that proton therapy is superior to or more
beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton
beam therapy on clinical trials, and to not routinely offer it to patients.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of proton beam radiotherapy have not been met. Therefore, we decided that the
Plan does not have to pre-approve proton beam radiotherapy.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approvecontinued treatment with Retacrit.You asked the Plan to pre-approvethe Retacrit treatment. You say that this treatment should continue to address ongoing anemia.The Plan denied your request. The Plan says that there is no myelosuppressive chemotherapy which is required for coverage.The Plan follows Medicare rules. Medicare rules say that ESA treatment, such as with Retacrit, is considered reasonable and necessary when the above criteria are met. 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 Retacrit treatment. Our reviewer says that the requested continuation of treatment with Retacrit is considered medically reasonable and necessary. Our physician reviewer found the patient is receiving gemcitabine and oxaliplatin for recurrent lymphoma with a hemoglobin reading of 9.1 on 1/19/2021. Since the hemoglobin level is below 10 on chemotherapy, this is considered necessary. Continuation of this treatment does not require a certain iron level.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 Retacrit treatment have been met.Therefore, we decided that the Plan has to pre-approvecontinued treatment with Retacrit.
If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvethe laparoscopic roux en y gastric bypass.You asked the Plan to pre-approvethe laparoscopic roux en y gastric bypass. You say that you would like reconsideration because the member is suffering from complications from her original sleeve surgery, has developed significant bile reflux, dysphagia and dysmotility and weight regain.The Plan denied your request. The Plan says that the information provided does not show psych evaluation, inability to lose weight with management or that treatable causes have been ruled out.The Plan must followMedicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and applythe relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the laparoscopic roux en y gastric bypass. Our reviewer says that the requested items/services are considered medically reasonable and necessary in thiscase. Our physician reviewer found the member meets all primary criteria for bariatric surgery. Conversion to laparoscopic roux en y gastric bypass is a standard operative treatment for post sleeve gastrectomy GERD and bile reflux.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 laparoscopic roux en y gastric bypass have been met.Therefore, we decided that the Plan has to pre-approvethe laparoscopic roux en y gastric bypass.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that the patient needs medical management with daily physician involvement, daily lab management and nutritional consult for assistance among other necessities listed in the appeal.The Plan denied your request. The Plan says that the enrollee has not completed the full course of care in the hospital.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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for initial hospital care provided on June 2, 2020.
You asked the Plan to waive the deductible for initial hospital care. You say that you were not aware that the doctor was out-of-network. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,000 deductible for inpatient hospital care. You received initial hospital care on June 2, 2020. The record shows that you had only paid $392.22 toward the $1,000 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $166.23. The item or service you asked the Plan to waive the deductible for falls within the benefit category inpatient hospital care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible for inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time initial hospital care was received on June 2, 2020. Therefore, we decided that the Plan does not have to waive the deductible for initial hospital care provided on June 2, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Sandostatin LAR Depot Kit 20mg.
You asked the Plan to pre-approve Sandostatin LAR Depot Kit 20mg. You say that the requested Sandostatin
LAR Depot Kit 20mg is medically necessary. The Plan denied your request. The Plan says that the requested
Sandostatin LAR Depot Kit 20mg is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA approved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Sandostatin LAR Depot Kit 20mg. Our
reviewer says that the requested Sandostatin LAR Depot Kit 20mg is medically necessary. Our physician
reviewer found the enrollee has ongoing GI bleeding from an unclear source in spite of extensive evaluation
and is refractory to standard therapy. In this circumstance of no clear source and refractory bleeding
pharmacologic therapy may be considered, including use of octreotide, according to expert guidelines.
Octreotide has demonstrated some success in this situation. Medical necessity criteria are met since "FDA
approved drugs used for indications other than what is indicated on the official label may be covered if the use
is determined to be medically accepted, taking into consideration the major drug compendia, authoritative
medical literature and/or accepted standards of medical practice."
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Sandostatin LAR Depot Kit 20mg have been met. Therefore, we decided that
the Plan has to pre-approve Sandostatin LAR Depot Kit 20mg.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forComputed Tomography (CT) scan (72131) provided June 25, 2020.You asked the Plan to waive the copayment forthe CT scan. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment 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 $125 copayment for diagnostic radiology. You have been asked to pay the allowable amount of $109.76 as a copayment for the CT scan. The CT scan falls within the diagnostic radiology benefit category. The allowable amount is less than the $125 copayment listed in the plan contract. This meansthat 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 forComputed Tomography (CT) scan (72131) provided June 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe seat lift mechanism.You asked the Plan to pre-approvethe seat lift mechanism. You say that you would like reconsideration because the seat lift mechanism is medically necessary.The Plan denied your request. The Plan says you do not meet criteria for coverage.The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met.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 seat lift mechanism. Our reviewer says that there is no documentation that a seat lift is included in the treating practitioner's course of treatment. There is no documentation that a seat lift is likely to effect improvement in your condition or arrest or retard deterioration in your condition. Our physician reviewer found based on the medical records provided there is no documentation that you are completely incapable of standing from a chair in the home. The provided certificate of medical necessity reports that you do not have the ability to ambulate.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 seat lift mechanism have not been met.Therefore, we decided that the Plan does not have to pre-approvethe seat lift mechanism
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora diagnostic consultation (D9310) received on July 24, 2020.You asked the Plan to pay fora diagnostic consultation. You say that you regard the denial of these claims as errors.The Plan denied your request. The Plan says rules for payment have not been met.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 fora diagnostic consultation (D9310) received on July 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fordomiciliary or rest home visit (99334) provided January 11, 2019.You asked the Plan to waive the copayment fordomiciliary or rest home visit. You say that you could not appeal this within the sixty-day time frame because you were not billed until twentymonths after the date of service and thirteenmonths after you received the Explanation of Benefits.The Plan denied your request. The Plan says this claim was processed and the correct copayment applied per the Evidence of Coverage.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 $45 copayment per specialist visit. You have been asked to pay $45 copayment per specialist visit.  The domiciliary or rest home visit falls within the Physician/Practitioner services, including doctor's office visits 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 fordomiciliary or rest home visit (99334)provided January 11, 2019.