Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (99183).
You asked the Plan to pre-approve HBO therapy. You say that the service is necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that HBO therapy is covered when specific criteria is 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 HBO therapy. Our reviewer says that
the service is not medically necessary. Our physician reviewer found the review has determined that you do not
meet any of the coverage criteria.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of HBO therapy have not been met. Therefore, we decided that the Plan does not
have to pre-approve hyperbaric oxygen (HBO) therapy (99183).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a Root canal and core build up (D3330, D2950) provided
November 19, 2019 
You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the services are not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a Root
canal and core build up (D3330, D2950) provided November 19, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the manual wheelchair provided from January 23, 2019 to August 23, 2019.You asked the Plan to waive the coinsurance for the manual wheelchair. You say that that you no longer have the wheelchair.The Plan denied your request. The Plan says that you are responsible for the 20% coinsurance until the item is either returned or the purchase price has been met.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Durable medical equipment (DME) and related supplies. You have been asked to pay a 20% coinsurance for the manual wheelchair. The manual wheelchair falls within the Durable medical equipment (DME) and related supplies 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 manual wheelchair provided from January 23, 2019 to August 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on August 10, 2019.You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger. You say that this was a mandatory service.The Plan denied your request. The Plan says payment of this service is included in the DRG payment.The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on August 10, 2019
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAransep.You asked the Plan to pre-approveAransep. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee has not tried Retacrit as required by Step therapy rules.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 Aransep. Our reviewer says that the criteriafor coverage of Aransep have not been met. Our physician reviewer found the Plan requires a trial of drug Retacrit before they will approve the requested drug. The documentation does not support that the enrollee has tried Retacrit or that this drug wouldlikely be less effective 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 Aransep have not been met.Therefore, we decided that the Plan does not have to pre-approveAransep.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Duloxetine Hcl.You asked the Plan to pre-approve Duloxetine Hcl. You say that the requested medication is necessary.The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.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 Duloxetine Hcl.Benefits for Duloxetine Hcl 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neulasta (J2505).
You asked the Plan to pre-approve Neulasta. You say that the medication is necessary. The Plan denied your
request. The Plan says the original Medicare contractor is responsible for the covered routine costs associated
with a clinical trial.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in
Original Medicare and the plan cost-sharing for the same services.
In this case, you asked the Plan to pre-approve Neulasta as part of a clinical trial. The Plan does not cover
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to preapprove
Neulasta (J2505).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient stay for a stent placement.
You asked the Plan to pre-approve the inpatient stay. You say that you live far from the hospital and the service
should be provided in the inpatient setting. The Plan denied your request. The Plan says the procedure can
safely be performed in an outpatient setting.
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 inpatient stay. Our reviewer says
that the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found while the stent placement is medically necessary, the services can be provided in an outpatient
setting. There are no preoperative conditions that suggest complications.
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 inpatient stay have not been met. Therefore, we decided that the Plan does
not have to pre-approve an inpatient stay for a stent placement.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility care (SNF)
admission and services.
You asked the Plan to pre-approve SNF care. You say that an inpatient skilled nursing facility care admission is
medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet
criteria for coverage of a 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 SNF care. Our reviewer says that a
skilled nursing facility care admission is not medically necessary. Our physician reviewer found that the
enrollee does not require skilled nursing or skilled therapy services on a daily basis. As a practical matter, the
enrollee does not require the necessary services on 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, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve an inpatient skilled nursing facility care (SNF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fo rthe periodontal scaling and root planing (D4341).You asked the Plan to pay for the dental services. You say that you are in excruciating pain, is on fixed income and cannot afford to pay for the service. Before you can get the tooth extraction you need to get the deep cleaning first.The Plan denied your request. The Plan says the requested service is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on November 1, 2019.You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 a drug test provided on November 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on August 16, 2019.You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does 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 valid physician order or clear intent to order the specific lab tests 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 on August 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe transplantation of blood-derived stem cells provided at  on July 19, 2019.You asked the Plan to waive the copayment forthe transplantation of blood-derived stem cells. You say that you feel that the service should be considered an infusion, not an outpatient surgical procedure.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 a $250 copayment for outpatient surgery, including servicesprovided at hospital outpatient facilities and ambulatory surgical centers. You received the transplantation of blood-derived stem cells on July 19, 2019. This is considered an outpatient surgical procedure, not an infusion. Therefore, you are responsible to pay $75, which is less than the $250 copayment. You have been asked to pay $75 for the transplantation of blood-derived stem cells. The transplantation of blood-derived stem cells falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 transplantation of blood-derived stem cells provided on July 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say thatIRF 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 by a physical medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. They may benefit from further physical therapy (PT) and occupational therapy (OT) but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 there is no reason to think that an intensive rehabilitation therapy program would significantly impact your condition differently compared with therapy provided at a less intense level. Your care can be appropriately provided through based care with home health 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post-stabilization inpatient care provided July 13, 2019 to
July 16, 2019
You asked the Plan to pay for the post-stabilization inpatient care. You say that the services were medically
necessary. The Plan denied your request. The Plan says the services were not preauthorized.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,
approval is required.
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 post-stabilization inpatient care. Our
reviewer says that the enrollee was stable for transfer to a plan facility after stabilization. Our physician
reviewer found the treating physician did not document (in the physician notes, on a form, or in an order) that
the patient was not stable for transfer on any dates of service. The enrollee could have been transferred via
ambulance to a plan facility for inpatient admission.
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 post-stabilization inpatient care have not been met. Therefore, we decided
that the Plan does not have to pay for post-stabilization inpatient care provided July 13, 2019 to July 16, 2019
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the radiation therapy provided on December 2, 2019.You asked the Plan to waive the copayment for the radiation therapy. You say that you should not be liable for the cost share due to the high cost. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $60 copayment for each in-network Medicare-covered radiation (radium and isotope) therapy service. You have been asked to pay a $60 copayment for the radiation therapy. The radiation therapy falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 for the radiation therapy provided on December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on July 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you are the provider for the the plan The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for skilled nursing services provided on July 10, 2019 by an out of network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve varicose vein treatment (36471).You asked the Plan to pre-approve varicose vein treatment. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee is not symptomatic.The Plan follows Medicare rules. Medicare rules say that varicose vein treatment is considered medically necessary if the patient remains symptomatic after a six-week trial of conservative 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 varicose vein treatment. Our reviewer says that the requested procedure is not medically necessary at this time. Our physician reviewer found the patient specifically denies any pain or cramping in her legs after exertion. Edema is absent. There are no skin changes. The documentation does not show that she has the required symptoms to be considered symptomatic.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of varicose vein treatment have not been met.Therefore, we decided that the Plan does not have to pre-approve varicose vein treatment (36471).