Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Praulent pre-filled pen injector.
You asked the Plan to pre-approve self-administered drugs. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
The Plan 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 Praulent pre-filled pen injector.
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration (20939).
You asked the Plan to pre-approve the bone marrow aspiration. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the member's condition does not meet the requirements for this service.
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 bone marrow aspiration. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspiration remains experimental in spinal surgery and more research is needed. 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 bone marrow aspiration have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration (20939).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 16, 2019.You asked the Plan to pay for the physician service. You say that you were not aware there was a requirement for a referral.The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee.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.You are not a network provider with the Plan. 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 office visit provided on May 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya.You asked the Plan to pre-approve Ilumya. The Plan denied your request. The Plan says that they did not receive documentation or medical records supporting the medical necessity for a step therapy exception.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 Ilumya. Our reviewer says that Ilumya is not medically reasonable and necessary in this case. The provided medical records do not indicate that you have tried and failed the required drugs or that they would likely be less effective and/or likely have adverse effects. Our physician reviewer found that your condition does not meet criteria for coverage of Ilumya.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ilumya have not been met.Therefore, we decided that the Plan does not have to pre-approve Ilumya.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Optune Plus tumor treatment field therapy.
You asked the Plan to pre-approve tumor treatment field therapy. You say that the Optune is a promising
option for the enrollee. The Plan denied your request. The Plan says the enrollee's diagnosis is not newly but
recurrent.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of tumor treatment field therapy have not been met. Therefore, we decided that the Plan does not have
to pre-approve Optune Plus tumor treatment field therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, electrocardiogram (EKG) complete, blood
draw, and urinalysis provided on July 31, 2019 by the out of network provider.
You asked the Plan to pay for the physician services. You say that the provider was not aware that he was not
in network. The Plan denied your request. The Plan says authorization was not obtained before the services
were provided to the enrollee. The Plan also says the services were not urgent or emergent.
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 the office visit, electrocardiogram (EKG)
complete, blood draw, and urinalysis provided on July 31, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.You asked the Plan to pre-approve a shower chair. You say that it is necessary for you to have the shower chair. You say that you cannot take a bath because you cannot get up from a tub and you get dizzy when you are standing. You say that the shower chair would allow you to get clean without risking a fall.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crown-porcelain fused to predominantly base
metal teeth 18, 20 and 21 (D6751) and pontic -porcelain fused to predominantly base metal tooth 19 (D6241).
You asked the Plan to pre-approve the dental services. You say that you need dental work done and cant seem
to be able to get it. The Plan denied your request. The Plan says the benefit limit for the requested services has
been exhausted.
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 health plan contract says
that these services are limited to once every 5 years. Records show that these services was provided May 21,
2018.
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
retainer crown-porcelain fused to predominantly base metal teeth 18, 20 and 21 (D6751) and pontic -porcelain
fused to predominantly base metal tooth 19 (D6241).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (88342-TC) provided on May 23, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service was already paid.The Plan must follow Medicare rules. Medicare rules say that if the technical and professional components of the service are performed by the same provider, then it is not appropriate to report the components of the service separately.. We looked at the file and Medicare rules. As the global service (88342) was also billed for the date of service in question, it is inappropriate to bill the technical component separately, as this is included in the global service. The records show that payment was made for the global service. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for the services (88342-TC) provided on May 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to approve in-network coverage for the medical services to be provided
by out of network (OON) ear-nose-throat (ENT) provider.
You asked the Plan to approve in-network coverage for the OON ENT services. You say that you were seen by
a provider in the past due to a CSF leak and you are having similar symptoms. You refuse to be seen by any
other provider since they did not know how to treat this the last time. The Plan denied your request. The Plan
says in this case, there are ENT providers able to assess and treat your condition. Since there is no network
deficiency, you must use your OON benefits if you wish to see this 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 approve in-network coverage 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. We found no exception that would require
the Plan to approve in-network coverage for these items/services. Therefore, we decided that the Plan does not
have to approve in-network coverage for the medical services to be provided by out of network (OON) earnose-
throat (ENT) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four (testing to monitor the depth of muscle relaxation during surgery) (95999 Unlisted neurological or neuromuscular diagnostic procedure (As per records: TRAIN OF FOUR provided to the enrollee on July 25, 2018.You asked the Plan to pay for the services. You say that the claim should be paid.The Plan denied your request. The Plan says the record sent by the provider indicates that the enrollee required neurophysiology monitoring for surgery and this has been approved, but the Train of Four testing cannot be approved for separate payment since it is bundled into the payment for the neuromonitoring.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. This service, train of four, is considered integral to the primary procedure, neurophysiology monitoring and therefore is part of a bundled payment.Therefore, we decided that the Plan does not have to pay for train of four (testing to monitor the depth of muscle relaxation during surgery) (95999 Unlisted neurological or neuromuscular diagnostic procedure (As per records: TRAIN OF FOUR provided to the enrollee on July 25, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider.
You asked the Plan to pre-approve injections. You say that you are uncomfortable with the in-network providers. The Plan denied your request. The Plan says there are in-network providers available.
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 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. 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 the medical services to be provided by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is not able to be independent getting out of bed. The Plan denied your request. The Plan says the need for ongoing management of active or acute chronic medical conditions 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 physician reviewer found that the enrollee's current level of function is minimal assist with bed mobility and transfers. She is ambulating at contact guard assist with a rolling walker. The enrollee is medically stable with no evidence of need for supervision by an acute rehab physician, or acute rehab nursing care. The enrollee may benefit from further physical and occupational therapy, but does not require an intensive therapy program. Therefore, an IRF admission is not medically necessary. 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from aggressive therapies in the inpatient rehabilitation setting in order to return home safely and efficiently with family support.The Plan denied your request. The Plan says Medicare guidelines for coverage have not been met. The plan says that the enrollee could receive the necessary care in another setting.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 is a female admitted to the hospital on 12/30/2019 due to a fall at home. She was found to have UTI, acute kidney injury, and high potassium levels. Based on review of available records, the patient does not meet criteria for coveragefor an IRF admission. She is medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient PMR physician three times per week or need for acute rehab nursing care. While she may benefit from continuing PT and OT, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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 Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on May 15, 2019.You asked the Plan to pay for the outpatient hospital services. You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered as billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We looked at the file and Medicare rules. The file shows the claim was billed without the G0 condition code which caused CPT code G0463 to deny.Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided on May 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve onabotulinumtoxin A (Botox) injection.
You asked the Plan to pre-approve Botox injection. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the use of Botox for the enrollee's condition is considered unproven.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Botox injection. Our reviewer says that the enrollee does not meet the Medicare criteria for Botox injections. Our physician reviewer found the documentation submitted does not support that the requested Botox is medically reasonable and necessary for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox injection have not been met. Therefore, we decided that the Plan does not have to pre-approve onabotulinumtoxin A (Botox) injection
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture.
You asked the Plan to pre-approve acupuncture. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. The services at issue in this appeal are acupuncture services. Therefore, we decided that the Plan does not have to pre-approve acupuncture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visits.You asked the Plan to pre-approve the rheumatology services. You say that the enrollee needs continuing rheumatology care. You also say that rheumatology care availability in the enrollee's network is poor.The Plan denied your request. The Plan says the requested services can be provided in network. 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 pre-approved care.You are 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 the office visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.
You asked the Plan to pre-approve the additional physical therapy services. You say that the records provided support the need for additional outpatient physical therapy visits. The Plan denied your request. The Plan says the additional physical therapy services are not medically necessary. The plan says that, at this point in time, a home program to manage the enrollee's problem is reasonable.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 the additional physical therapy services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested therapy is no generally accepted as specific and effective therapy for the enrollee's condition after the progress she has made with 90-95% recovery noted. Our physician reviewer found that the enrollee was able to do her exercises at home with a home exercise program and made progress. Our physician reviewer found that the unique skills of a professional therapist are not required to safely and effectively provide treatment. 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 additional physical therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Life Alert bracelet (A9280).
You asked the Plan to pre-approve the Life Alert bracelet. You say that it is advertised on TV that Medicare would cover this item. You need this due to medical reasons because you have fallen and used the medical alert. The Plan denied your request. The Plan says this item is not a Medicare covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve Life Alert bracelet (A9280).