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

We decided that the Plan does not have to pre-approve Retacrit.
You asked the Plan to pre-approve the Retacrit. You say that you would like reconsideration because Retacrit is medically necessary. The Plan denied your request. The Plan says the documentation does not show that the member has a condition for which the use of Retacrit is indicated.
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 the Retacrit. Our reviewer says that the requested use of Retacrit is not FDA-approved for the member's condition. Our physician reviewer found the use is also not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 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 have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
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 you are in pain and have low mobility. The Plan denied your request. The Plan says you would not be able to participate in or fully benefit from IRF care.
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 based on the medical records, you do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needs can be met at a lower level of care 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedental services (D0210, D2920).You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no coverage for these services.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 Plandoes not haveto pre-approvedental services (D0210, D2920)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOmeprazole capsules.You asked the Plan to pre-approveOmeprazole capsules. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Omeprazole capsules are not covered under the enrollee's Medicare Part B benefit.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-approveOmeprazole capsules.Benefits for Omeprazole capsulesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvegenicular nerve radiofrequenxy.You asked the Plan to pre-approvethe genicular nerve radiofrequency. You say that you would like reconsideration because this service is medically necessary.The Plan denied your request. The Plan says this service is experimental.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 genicular nerve radiofrequency. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this service is experimental and is the subject of ongoing clinical trials.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 genicular nerve radiofrequency have not been met.Therefore, we decided that the Plan does not have to pre-approvegenicular nerve radiofrequenxy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tremfya.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says self-administered drugs are not covered.
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 Tremfya.
Benefits for these services 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: 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 IRF care is necessary.The Plan denied your request. The Plan says admission to an IRF is not medically necessary.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 does not require the intensity of services provided at an IRF. Specifically, the enrollee does not require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care could have been met at a lower level of care.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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecomputed tomography (CT) scans of the abdomen and pelvis (74176) and thorax (71250).You asked the Plan to pre-approveCT scans of the abdomen, pelvis, and thorax. You say that this is medically necessary.The Plan denied your request. The Plan says this is not indicated.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 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 CT scans of the abdomen, pelvis, and thorax. Our reviewer says that the criteria for coverage of the requested CT scans have not been met. Our physician reviewer found the medical records provided do not support the medical necessity of these CT scans.  The CT scans are needed for initial staging of bladder cancer and when their is concern about recurrence. The records do not show either of these situations is present.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scans of the abdomen, pelvis, and thorax have not been met.Therefore, we decided that the Plan does not have to pre-approvecomputed tomography (CT) scans of the abdomen and pelvis (74176) and thorax (71250).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital stay beyond January 29, 2021.
You asked the Plan to pre-approve the inpatient services. You say that you cannot go home, you are in too
much pain. The Plan denied your request. The Plan says the enrollee did not meet medical necessity for
inpatient care.
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 services. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee was considered medically stable for lower level of care, and therefore
coverage of continued hospital observation stay beyond January 29, 2021 was not medically indicated.
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 services have not been met. Therefore, we decided that the Plan
does not have to pre-approve inpatient hospital stay beyond January 29, 2021.
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 you feel that you need the higher level of medical and rehab care so that you can return to baseline.The Plan denied your request. The Plan says your medical conditions are stable with low complexity. You do not require frequent oversight by a physician. You are also not likely to be able to participate in three daily hours of therapy.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 admitted to the hospital on 1/5/2021 with COVID-19. The enrollee currently requires minimal assistance forstanding, moderate assist for bathing, and maximal assist for lower body dressing. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of careWe 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forintravenous infusions provided from July 6, 2020, to July 10, 2020.You asked the Plan to waive the copayments forintravenous infusions. You say that you disagreewith the charges because you had the same services at another facility and was charged much less.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 $200 copayment for outpatient surgery, including services provided at hospital outpatient facilities.You received intravenous infusions from July 6, 2020, to July 10, 2020, at an outpatient hospital facility for a total of 5 visits. Therefore, you are responsible to pay the allowed amount of $186.96 per each visit. The total amount you owe is: $186.96 (allowed amount) x 5 (visits) = $934.80.You have been asked to pay the total copayment amount of $934.80 for intravenous infusions. Intravenous infusions fall 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 youenrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayments forintravenous infusions provided from July 6, 2020, to July 10, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating physician on September 3, 2020.You asked the Plan to waive the coinsurance for an injection. You say that the injection did not work and you do not think that you should have to pay for this. The Plan denied your request. The Plan says the correct coinsurance 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. You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The allowed amount is $1,166. The total amount you are being asked to pay is $233.20 ($1,166 x 20% = $233.20). An 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 for an injection provided by aparticipating physician on September 3, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 17, 2020, by an
OON provider.
You asked the Plan to pay for nursing facility care. You say that these medically necessary services were
provided to the enrollee in good faith and the provider should not be penalized for the hospital staff's failure to
take the proper steps to obtain authorization. The Plan denied your request. The Plan says rules for payment
have not been met.
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 had network providers
available who could have provided 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 August 17, 2020,
by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean interspinousspacer (22869).You asked the Plan to pre-approvean interspinous spacer. You say that the requested item/service is medically necessary.The Plan denied your request. The Plan says rules for pre-approval have not been met.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 indenying the request to pre-approve an interspinous spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the spacer is experimental. 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 an interspinous spacer have not been met.Therefore, we decided that thePlan does not have to pre-approvean interspinous spacer (22869).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance services (A0427) received on July 2, 2020.You asked the Plan to waive the copayment forthe ambulance services. You say that you were not capable at the time of ambulance transport of asking the ambulance service if they were associated with the Plan.The Plan denied your request. The Plan says you were charged this cost sharing 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 $260 copayment for each ambulance trip. You had 1 ambulance trip. The Plan charged you $260 for these services. 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 enrolledin the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe ambulance services (A0427) received on July 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSynvisc-One (J7325).You asked the Plan to pre-approveSynvisc-One. You say that you would like reconsideration because this drug is medically necessary.The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Synvisc-One. Our reviewer says that the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Our physician reviewer found the documentation does not outline contraindications or reasons these medications were not considered.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met.Therefore, we decided that the Plan does not have to pre-approveSynvisc-One (J7325
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe repeat echocardiogram.You asked the Plan to pre-approvethe repeat echocardiogram. You say that you would like reconsideration because this service is medically necessary.The Plan denied your request. The Plan says the member does not have any new signs or symptoms to suggest a need for the echocardiogram.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 repeat echocardiogram. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the member is clinically stable with only mild-to-moderate valve disease as shown on the echocardiogram which was rendered less than one year ago.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 repeat echocardiogram have not been met.Therefore, we decided that the Plan does not have to pre-approvethe repeat echocardiogram
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visit provided on January 14, 2020.

You asked the Plan to waive the copayment for the outpatient office visit. You say that you never saw the doctor as a patient and you only spoke to the doctor while attending an open house. The Plan denied your request. The Plan says you did not receive the service from your designated primary care physician on January 14, 2020.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the medical records show that you received the outpatient office visit on January 14, 2020. You were asked to pay a $40 copayment for the services. Your 2020 EOC states enrollees must pay a $0 copayment for PCP visits received from a preferred primary care physician (PCP), a $5 copayment for PCP visits received from a standard primary care physician and a $40 copayment per specialist visit. 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 outpatient office visit provided on January 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex surgery.
You asked the Plan to pre-approve the Vertiflex surgery. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is considered experimental and no coverage is available.
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 Vertiflex surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the spacer device is experimental. It is necessary for more research to show safety and efficacy of the device. 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 Vertiflex surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex surgery.