Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Lucentis (J2778).
You asked the Plan to pre-approve Lucentis. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been met.
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 Lucentis. Our reviewer says that the requested drug is not medically necessary in this case. Our physician reviewer found that the Plan requires a trial of preferred drug Bevacizumab before they will approve the requested drug. The enrollee has not tried and failed the preferred drug. The documentation in the case file does not support that Bevacizumab 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 Lucentis have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Lucentis (J2778).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone marrow aspiration procedure for bone grafting in spine surgery (20939).
You asked the Plan to pre-approve a bone marrow aspiration for bone grafting. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is experimental/investigational.
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 a bone marrow aspiration for bone grafting. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that bone marrow aspiration remains experimental for use as bone graft material in spinal surgery. 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 a bone marrow aspiration for bone grafting have not been met. Therefore, we decided that the Plan does not have to pre-approve a bone marrow aspiration procedure for bone grafting in spine surgery (20939).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visit with an otolaryngologist and nasal endoscopy you had on April 27, 2021.
You asked the Plan to waive the copayments for the otolaryngology visit and the nasal endoscopy. You say that you are not happy with being charged these copayments. The Plan denied your request. The Plan says you were charged these copayments 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 $45 copayment for visits with a specialist and a $50 copayment for diagnostic tests. You have been asked to pay a $45 copayment for the otolaryngology visit and a $50 copayment for the nasal
endoscopy. The otolaryngology visit falls within the visits with a specialist benefit category and the nasal endoscopy falls in the diagnostic test 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 copayments for the office visit with an otolaryngologist and nasal endoscopy you had on April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from October 27, 2020, through November 16, 2020.
You asked the Plan to pay for the dental services. You say that you knew you didn't need to have a network dentist to be reimbursed so you resubmitted the paid receipts. You say that you were not informed the doctor had opted out of Medicare and the denial for reimbursement should be reconsidered. The Plan denied your request. The Plan says payment cannot be issued for services performed by a provider who has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental services provided from October 27, 2020, through November 16, 2020.
Your complaint about being given wrong information is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) and the acupuncture treatment (97810, 97811) rendered by the out-of-network (OON) provider from April 12, 2021, through April 27, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 office visit (99203) and the acupuncture treatment (97810, 97811) rendered by the out-of-network (OON) provider from April 12, 2021, through April 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on April 20, 2020.

You asked the Plan to waive the copayment for the ambulance services. You say that you were not aware that there would be a copayment for this service. The Plan denied your request. The Plan says you were charged this copayment 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 $225 copayment for ambulance services. 

You have been asked to pay a $225 copayment for the ambulance 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 enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services you received on April 20, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sensor (A9276).

You asked the Plan to pre-approve the sensor. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered as it is considered precautionary.

The Plan must follow Medicare rules. The rules say A9276 is not a covered code. 

The requested monitor sensor is coded in such a way that makes it statutorily not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a sensor (A9276).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you had on March 17, 2021.

You asked the Plan to waive the copayment for the lab services. You say that you have never had a copayment for blood work before. The Plan denied your request. The Plan says you were charged this copayment 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 $15 copayment for lab services. 

You have been asked to pay a $15 copayment for the lab 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 enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for lab services you had on March 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5225).

You asked the Plan to pre-approve the maxillary partial denture. You say that you are disabled and have an eating disorder. You also say that you are unable to chew using your front teeth, and you have no side teeth. The Plan denied your request. The Plan says this service is not covered under your benefit package.

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 pre-approve a maxillary partial denture (D5225).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan of the soft tissue of the neck (70491).

You asked the Plan to pre-approve a CT scan of the soft tissue of the neck. You say that the requested
procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for
coverage for CT scans have not been met because the requested procedure is not 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 a CT scan of the soft tissue of the neck.
Our reviewer says that the requested procedure is not medically necessary in this case. Our physician reviewer
found that that a soft tissue neck ultrasound was ordered and signed off with a final report on August 6,
2021. Results are not in the case record. Absent an abnormal physical exam or equivocal ultrasound of the area
in question, the medical necessity of a CT scan of the soft tissue of the neck has not been established.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a CT scan of the soft tissue of the neck have not been met. Therefore, we
decided that the Plan does not have to pre-approve a CT scan of the soft tissue of the neck (70491).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be safely managed at a skilled nursing facility and requires prolonged hospitalization as well as the intensive skilled services that are offered in the LTACH setting. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the records do not show that the enrollee has completed a full course of care in the hospital.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he/she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a motorized wheelchair, unspecified.

You asked the Plan to pre-approve a motorized wheelchair. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says rules for power mobility devices have not been met.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

The ordering physician in this case did not provide a procedure code to specify the motorized wheelchair being requested. The available documentation in the case record is insufficient to show that you can safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a motorized wheelchair, unspecified.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 60 additional one-way routine transportation trips.

You asked the Plan to pre-approve 60 additional one-way trips. You say that you have no means of transportation or family support and that without Plan transportation your health care is in jeopardy. The Plan denied your request. The Plan says rules for routine transportation have not been met.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way trips per year.

We looked at your request, the records in the case file, and the rules. The case record states that you have used 53 of the allowed 60 one-way trips. You have 7 one-way trips remaining before you will exhaust the Plan maximum benefit for coverage of routine transportation. There is no provision in the Plan contract for an exception to the maximum benefit. Therefore, we decided that the Plan does not have to pre-approve 60 additional one-way routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental implants (D6010).
You asked the Plan to pre-approve implants. You say that there is nothing more that can be done to help you have a functioning chewing system in your mouth. You say that you need implants in order to keep the dentures firm and in place. You also say that you cannot afford to pay for this. The Plan denied your request. The Plan says implants are not listed as covered 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 Plan does not have to pre-approve dental implants (D6010).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to preapprove additional routine transportation trips (A0120).
You asked the Plan to preapprove routine transportation. You say that you need the additional transportation to get to your Doctor appointments. The Plan denied your request. The Plan says you have exhausted your Plan benefit for routine transportation.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 52 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to preapprove additional routine transportation trips (A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) provided December 18, 2020.
You asked the Plan to pay for the bitewing x-rays. You say that you would like the service covered. The Plan denied your request. The Plan says the claims from this date of service have been reprocessed however you have exceeded frequency limits for the bitewing x-rays.
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 the bitewing x-rays once per calendar year.
We looked at the file and Medicare rules. The Plan provided documentation showing that a set of bitewing x-rays was previously covered on June 17, 2020. Based on this information, we determined that the Plan's frequency limit for the bitewing x-rays has been exceeded. Therefore, we decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) provided December 18, 2020.
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 disagree with the denial. The Plan denied your request. The Plan says the services are 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 in the Medicare rules section. 

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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with knee pain after a fall and acute kidney injury. He is now medically stable with no complex nursing or rehabilitation needs. He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from February 20, 2021 to February 26, 2021.

You asked the Plan to pay for home health services. You say that this should be covered in-network. The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. 

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this was not billed with the correct type of bill. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from February 20, 2021 to February 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) and the laboratory services (80307, 82962) rendered by the out-of-network (OON) provider on November 19, 2020.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 office visit (99214) and the laboratory services (80307, 82962) rendered by the out-of-network (OON) provider on November 19, 2020.