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

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on June 11, 2019.
You asked the Plan to pay for the services. 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 the enrollee by an out-of-network provider on June 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve testosterone cypionate.
You asked the Plan to pre-approve self-administered drugs. You say that there is no other drug that can be prescribed for this enrollee to treat his condition. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits. The Plan also says that the enrollee's Medicare Part D prescription drug benefits may be administered by the Provider.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve testosterone cypionate.
Benefits for self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveZarxio (Filgrastim-sndz).You asked the Plan to pre-approvethe Zarxio. You say that the drug being requested is medically necessary.The Plan denied your request. The Plan says the information submitted does not meet the plans medical necessity guidelines for coverage.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 Zarxio. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of the drugs Neupogen and Nivestym before they will approve the requested drug. There is no evidence that the enrollee has tried and failed these required drugs. The documentation does not support that Neupogen (Filgrastim) and Nivestym (Filgastim-aafi) 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 Zarxio have not been met.Therefore, we decided that the Plan does not have to pre-approveZarxio (Filgrastim-sndz).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on September 26, 2019.You asked the Plan to waive the copayment forthe office visit. You say that youwere informed you wouldn't have a copayment.The Plan denied your request. The Plan says the copayment 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 $10 copayment for each primary care doctor visit for Medicare-covered benefits. You have been asked to pay a $10 copayment for the office visit. The office 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 forthe office visit provided on September 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveClobazam for the enrollee.You asked the Plan to pre-approvethis drug. The Plan denied your request. The Plan says that this medication does not fall 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-approveClobazam for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits forfurther information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemedical services to be provided by an out-of-network (OON) provider.You asked the Plan to pre-approvethe services. You say that this provider is highly recommended.The Plan denied your request. The Plan says the services are available in-network.Medicare rules say thatplans 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approvemedical services 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 forthe medical services provided to you by an out-of-network provider on September 12, 2019.You asked the Plan to pay forthe services. The Plandenied your request. The Plan says the services were provided according to the records.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 forthe medical services provided to you by an out-of-network provider on September 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a left hip nerve block procedure.
You asked the Plan to pre-approve the hip nerve block. You say that the enrollee would benefit from this treatment. The Plan denied your request. The Plan says this type of injection is not shown to be safe/effective.
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 hip nerve block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a male with osteoarthritis and degenerative changes in the left hip. He has tried NSAIDs and gabapentin and has had three prior hip injections. The requested procedure is experimental/investigational. There are no clinical practice guidelines that support this approach. This is medically unreasonable and unnecessary. 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 hip nerve block have not been met. Therefore, we decided that the Plan does not have to pre-approve a left hip nerve block procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-ray (D0272) provided on August 23, 2019.You asked the Plan to pay for the dental services. You say that you received the same services in 2018. You say that the services were covered in 2018. You also say that you did not realize that you changed plans.The Plan denied your request. The Plan says the periodic oral evaluation, prophylaxis, and bitewing x-rays are not listed as covered services.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-ray (D0272) provided on August 23, 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 the charges were never explained to you. You stated that you are disabled and Medicare always pays your bills. You say that you cannot afford to pay the ambulance claims. 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 August 30, 2019. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe percutaneous implantation of neurostimulator electrode array provided on November 5, 2019 by an OON provider.You asked the Plan to pay forthe percutaneous implantation of neurostimulator electrode array. You say that no pre-authorization is required.The Plan denied your request. The Plan says the services were rendered by a non-network provider who does not work with the enrollee's plan. The Plan also says that the enrollee self-directed for care.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 forthe percutaneous implantation of neurostimulator electrode array provided on November 5, 2019 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 28, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrolleemust 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 servicesat issue. We found no exception that would require thePlan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on October 28, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.You asked the Plan to pre-approve the continuation of skilled nursing facility (SNF) care. You say that the requested continuation of SNF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for the continuation of SNF care.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 the continuation of skilled nursing facility (SNF) care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to SNF on 1/31/20 after an acute hospital admission for falls at home and hypertension. The Plan approved SNF care from 1/31/20 to 3/11/20. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. He was alert with confusion. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the SNF. By the dates in question, the enrollee was at a supervision level with functional mobility including gait to 150 feet with a rolling walker.The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, wedecided that Medicare rules for coverage of the continuation of skilled nursing facility (SNF) care have not been met.Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forfoot orthotics provided on June 20, 2019.You asked the Plan to pay forfoot orthotics. You say that the Plan should pay this claim.The Plan denied your request. The Plan says there is no supporting documentation of criteria.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows thesesame rules.  The record does not show that the enrolleesuffersfrom diabetic foot disease orwearsa leg brace. Although orthotics may be appropriate forthe enrollee, the record does not contain a physician order, recent foot exam,or evidence of diabetic foot disease. Therefore, we decided that the Plan does not have to pay forfoot orthotics provided on June 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a blood pressure monitor/blood pressure monitoring during an ambulance transport provided on August 12, 2019.
You asked the Plan to pay for a blood pressure monitor or blood pressure monitoring during an ambulance transport. You say that the Plan should pay this claim. The Plan denied your request. The Plan says ambulatory blood pressure monitoring is only covered for suspected white coat hypertension and performed at least 24 hours.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code A4670 is automatic bp monitor, dial. We find that CPT code A4670 is not supported in the medical record. Specifically, the enrollee did not receive a blood pressure monitor during transport and blood pressure monitoring in an ambulance is not separately payable. Based on this information, we decided that Medicare rules for coverage of blood pressure monitoring during an ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for
a blood pressure monitor/blood pressure monitoring during an ambulance transport
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care can be received in alternate settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was medically stable with no evidence of need for supervision or needs acute rehab nursing care. She may benefit from further PT and OT at home but does not require an intensive therapy program. IRF admission is not medically necessary based on her current functional status and medical stability We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Portable Oxygen Concentrator System provided on May 30, 2019 by an out of network provider
You asked the Plan to reimburse you for the portable oxygen concentrator. You say that you want to be reimbursed for the oxygen concentrator. The Plan denied your request. The Plan says you did not request prior authorization.
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 reimburse you for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. Medicare rules say that only rented oxygen equipment is eligible for coverage. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the item at issue in this appeal. The Plan did not pre-approve the item at issue. Purchased oxygen equipment is statutorily non-covered by Medicare. We found no exception that would require the Plan to reimburse you for this item. Therefore, we decided that the Plan does not have to reimburse you for the Portable Oxygen Concentrator System provided on May 30, 2019 by an out of network provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transfer bench (E0247).
You asked the Plan to pre-approve the transfer bench. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the transfer bench is a convenience item and not primarily medical in nature.
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 transfer bench (E0247).
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 September 26, 2019.
You asked the Plan to pay for the services. 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 September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forpsychotherapy provided on September 24, 2019 by an out of network (OON) provider.You asked the Plan to pay forpsychotherapy. You say that you were unaware that prior authorization was required for these services.The Plan denied your request. The Plan says no prior authorization was obtained for these services.Medicare rules saythat 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 forpsychotherapy provided on September 24, 2019 by an out of network (OON) provider.