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

We decided that the Plan does not have to pre-approve Epogen.
You asked the Plan to pre-approve Epogen. 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 Epogen. Our reviewer says that the member has not tried and failed a two-month trial of Retacrit with appropriate dose adjustment. Our physician reviewer found there is no indication that the Plan's required drug would likely be less effective and/or likely have adverse effects for the member. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Epogen have not been met. Therefore, we decided that the Plan does not have to pre-approve Epogen.
Appeal type: Imaging
Decision: Favorable

We decided that the pre-approve a CT scan of the abdomen for the enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary.The Plan denied your request. The Plan says that the requested scan is not supported by evidence-based guidelines, nor is there evidence that it is medically necessary.

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 the scan. Our reviewer says that the requested scan is medically reasonable or necessary. Our physician reviewer found per the NCCN guidelines, a CT scan of abdomen can be yearly, for three years, or longer as clinically indicated. On this basis, the scan be approved.

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 scan have been met.Therefore, we decided that the Plan has to pre-approve a CT scan of the abdomen for the enrollee.

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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foroutpatient mental health services (90837) provided March 12, 2020.You asked the Plan to waive the copayment forthe outpatient mental health services. 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 $30 copayment for individual mental health services. You have been asked to pay a $30 copayment for the outpatient mental health services. The outpatient mental health services fall within the individual mental health services 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 foroutpatient mental health services (90837) provided March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shareforthe Aflibercept injection or outpatient facility visit provided on April 14, 2020.You asked the Plan to waive the copayments forthe Aflibercept injection. You say that you were not told there would be a charge for the injection.The Plan denied your request. The Plan says you were charged the cost share 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 thatyou must pay 20% coinsurance for Medicare Part B prescription drugs and a $275 copaymentfor Outpatient Hospital Facility Visit. You have been asked to pay 20% coinsurance for the Aflibercept injection. The Afliberceptinjection falls within the Medicare Part B prescription drugs benefit category. You have been asked to pay a $275 copayment for the Outpatient Hospital Facility Visit. The facility visit falls within the OutpatientHospital Facility Visitbenefit 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 cost shareforthe Aflibercept injection or Outpatient Facility visit provided on April 14, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea partial lower denture (D5214).You asked the Plan to pre-approvethe dental item. You say that the enrollee has dementia. You say that the enrollee has lost her dentures. You also say that she has gum irritation and is having issues eating properly.The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan also says that the frequency limit has been reached.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 frequency limit of dentures once every 5 years has been reached. The record shows that the Plan paid for a partial dentures that you received on April 19, 2017.Therefore, we decided that the Plan does not have to pre-approvea partial lower denture (D5214)
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the documentation fails to indicate that you require daily skilled nursing care with physician oversight at least weekly, complex wound care at least twice a day and one hour daily skilled therapy.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete upper denture and partial lower denture.
You asked the Plan to pre-approve complete upper denture and partial lower denture. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services exceed your benefit limit.
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 complete upper denture and partial lower denture when the services are medically necessary and reasonable. We looked at the file and Medicare rules. Review of the file shows that dentures are covered once every 60 months. The enrollee last received dentures on January 12, 2017. Sixty (60) months have not passed since the enrollee last received dentures. Based on this information, we decided that the Plan's rules for coverage of complete upper denture and partial lower denture have not been met. Therefore, we decided that the Plan does not have to pre-approve complete upper denture and partial lower denture.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that the member is a falls risk, high risk for injury and high readmission risk to acute care if he is not admitted to the IRF.The Plan denied your request. The Plan says that it is not reasonable to expect that the enrollee will be able to actively participate in, nor fully benefit from, the intensity of services of an IRF.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when itis 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. The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for weakness, fatigue, acute kidney failure, hematuria, anemia and an abdominal mass. He was discharged to skilled nursing on 2/5/2021. He is receiving physical therapy services and remains weak. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy services coded S9328 provided from July 30, 2020 to August 13, 2020.You asked the Plan to pay forthe home infusion therapy services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not payable.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 S9328 is home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code isnot valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy services coded S9328 provided from July 30, 2020 to August 13, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedental crowns (D2750).You asked the Plan to pre-approvedental crowns. You say that you would like the Plan to reconsider their denial.The Plan denied your request.The Plan says dental crowns with dental code D2750 are not covered under the Plan's supplemental dental 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 dental crowns with dental code D2750 are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvedental crowns (D2750).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe mechanical traction therapy (97012), therapeutic exercises (97110) and whirlpool therapy (97140) provided on February 4, 2020, through February 13, 2020.You asked the Plan to pay forthe mechanical traction therapy, therapeutic exercises and whirlpool therapy. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says these services are not Medicare or Plan covered benefits.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe mechanical traction therapy (97012), therapeutic exercises (97110) and whirlpool therapy (97140) provided on February 4, 2020, through February 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for
the bone replacement graft for ridge preservation (D7953) provided.

You asked the Plan to pay the in network rate for the bone replacement graft. You say that you have been seeing this dentist for 10 years. You say that the dentist advised during a tele dentistry visit that you had a severe infection and recommended an extraction, bone graft and implant. You say that the extraction should be covered per your Evidence of Coverage. You also say that you consider this procedure to be traumatic which required you to use this dentist whom you trust.The Plan denied your request. The Plan says bone replacement graft for ridge preservation is not listed as a covered service.

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 the in network rate for the bone replacement graft for ridge preservation (D7953) provided.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forlaboratory tests (87798,87633, 87581, 87486) and an electrocardiogram (93005) provided from August 17, 2020, to August 20, 2020.You asked the Plan to waive the coinsurance forlaboratory tests and an electrocardiogram. You say that you do not know who ordered these testsor why.The Plan denied your request. The Plan says these services processed correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for laboratory services, diagnostic procedures, and tests. You have been asked to pay a $283.74 coinsurance for laboratory tests and an electrocardiogram ($1,418.74allowed amount x 20% = $283.74). This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forlaboratory tests (87798, 87633, 87581, 87486) and an electrocardiogram (93005) provided from August 17, 2020, to August 20, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IV Dextran infusion services with an out of network
(OON) provider.

You asked the Plan to pre-approve the IV Dextran infusion services provided OON. You say that the enrollee
requires iron infusions intermittently due to anemia related to chronic kidney disease. You say that, based on
his lab work, the iron infusion is medically necessary. You say that you have been seeing the enrollee for his
kidney disease ongoing since 2019 and the Plan has been covering his visits with you. You say that denial of
the enrollee's medication will put him at higher risk for bleeding and further kidney failure. The Plan denied
your request. The Plan says the medication is approved as medically necessary, but the requested infusion site
is out of network. The Plan says that they would approve the IV Dextran infusion services to be administered at
an in-network site.

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 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 items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
IV Dextran infusion services with an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvechiropractic office visit services.You asked the Plan to pre-approvethe services. You say that this is medically necessary.The Plan denied your request. The Plan says Medicare does not cover non-manipulative services provided by chiropractors.The Plan must follow Medicare rules. The rules saythat the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pre-approvechiropractic office visit services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit and related services provided on November 27, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe office visit and related services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an OON provider.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 forthe office visit and related services provided on November 27, 2019 by an out of network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 28, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis whiletemporarily 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 Plandid not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on August 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Nitro rolling walker.
You asked the Plan to pre-approve the requested walker. You say that you suffer from persistent low back pain. The Plan denied your request. The Plan says you have not tried other available alternatives.
The Plan follows Medicare rules. Medicare rules say that walkers are only covered under certain medical indications. 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 requested walker. Our physician reviewer found that you have chronic low back pain due to sacroiliitis. The documentation does not support that the requested brand has features that are medically necessary for the enrollee in this case. The records do not show that a standard walker will not meet your needs. The records do not show that the specified brand is medically reasonable and necessary for your condition.
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 requested walker have not been met. Therefore, we decided that the Plan does not have to pre-approve a Nitro rolling walker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea lightweight manual wheelchair (K0003).You asked the Plan to pre-approvethe lightweight manual wheelchair. You say that the manual wheelchair is medically necessary.The Plan denied your request. The Plan says the plan has already approved a power mobility device. Additionally, the manual chair is intended for use outside the home.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. DME is not covered for use primarily outside the home.The file shows that the enrollee has a Power Mobility Device. a Power Mobility Device serves the same purpose as the lightweight manual wheelchair.Therefore, we decided that the Plan does not have to pre-approvea lightweight manual wheelchair (K0003).