Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveservices provided as part of a clinical trial.You asked the Plan to pre-approvethe services provided as part of a clinical trial. You say that the enrollee's chemotherapy was completely covered before, as were the follow-up scans. You say that the last scan discovered that the cancer reappeared and that the enrollee needs phase II done.The Plan denied your request. The Plan says medically necessary services, once enrolled in clinical trial, are paid for byoriginal fee-for-service Medicare.The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services.In this case, you asked the Plan to pre-approve the services provided as part of a clinical trial as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials.Therefore, we decided that the Plan does not have to pre-approveservices provided as part of a clinical trial.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro myoelectric orthosis (L8702).You asked the Plan to pre-approve the orthosis. You say that given that traditional rehab strategies have been tried and failed, the enrollee's physician is recommending him for myoelectric orthotic restoration.The Plan denied your request. The Plan says this item is considered experimental and investigational. There is insufficient evidence of its effectiveness in those with stroke and hemiparesis.The Plan must follow Medicare rules. Medicare rules say that experimental and investigational devices are not covered.We looked at  the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met.Therefore, we decided that the Plan does not have to pre-approve the MyoPro myoelectric orthosis (L8702).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered from October 7, 2019 to January 6, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered from October 7, 2019 to January 6, 2020.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro myoelectric orthosis (L8702) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the orthosis. You say that you are requesting and in network exception because MyoMo is not contracted with the plan directly and have verified that there are no trained providers in the enrollee's servicing area. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 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 MyoPro myoelectric orthosis (L8702) to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forcardiology services provided on October 31, 2019 by an out of network (OON) provider.You asked the Plan to pay forcardiology services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forcardiology services provided on October 31, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the bone replacement grafts for ridge
preservation-per site (D7953 x 2) provided on July 29, 2019.
You asked the Plan to issue reimbursement 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 these services are
not a covered benefit under your contractual policy.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to issue reimbursement for the bone
replacement grafts for ridge preservation-per site (D7953 x 2) provided on July 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient services provided on December 18, 2019 to January 15, 2020 by an out of network (OON) provider.You asked the Plan to pay foroutpatient services. You say that you understand that the long term care is not covered by the contract and ask that the provider be excluded from the denial.The Plan denied your request. The Plan says prior authorization was not obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay foroutpatient services provided on December 18, 2019 to January 15, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Tobramycin (J7682).
You asked the Plan to pre-approve a tier exception for Tobramycin. The Plan denied your request. The Plan
says this drug/device is covered by Medicare Part B. The Plan also says that Medicare rules say tier exceptions
(co-pay reductions) are not available for drugs/devices covered by Part B.
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping
Part D drugs into different cost sharing levels within a Part D sponsor's formulary.
We looked at the file and Medicare Rules. Based on this information we decided that Medicare rules for a tier
exception have not been met. Specifically, the drug at issue is being covered by the Plan under Medicare Part
B. Part B Drugs are not eligible for tier exceptions. Therefore, we decided that the Plan does not have to preapprove
a tier exception for Tobramycin (J7682).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Tenex procedure to the right hip for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied
your request. The Plan says there is not enough medical proof to show the safety and success of this procedure,
and therefore it is investigational and unproven.
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 procedure. Our reviewer says that
the requested procedure is not considered medically reasonable and necessary in this case. Our physician
reviewer found this procedure is experimental, and more research is needed to show safety and efficacy for hip
tendonitis.
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 procedure have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Tenex procedure to the right hip for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical nutrition therapy (97804) provided on February
6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for OON medical nutrition therapy. You say that this was medically necessary. The
Plan denied your request. The Plan says this was not authorized.
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 medical nutrition therapy (97804) provided on
February 6, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nerve block.You asked the Plan to pre-approve a nerve block. 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 medically necessary.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 nerve block. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic hip pain due to osteoarthritis. The enrollee had a left hip femoral and obturator articular branch nerve block in July 2017 with 70% pain relief until April 2018. A repeat block provided an additional 6 months of relief. The effectiveness and safety of femoral and obturator articular branch nerve blocks to treat hip pain has not been established. Femoral and obturator articular branch nerve blocks are not the standard of care for the treatment of osteoarthritis of the hip. As such, femoral and obturator articular branch nerve blocks are considered experimental/investigational in nature and are not reasonable and 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 a nerve block have not been met.Therefore, we decided that the Plan does not have to pre-approvea nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe urology services (51702, 00914, 52000,99100) provided from January 13, 2020 to March 4, 2020 by an out of network (OON) provider.You asked the Plan to pay forOON urology services. You say that these services should be paid.The Plan denied your request. The Plan says these serviceswere not authorized.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 forthe urology services (51702, 00914, 52000, 99100) provided from January 13, 2020 to March 4,2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex vein scan rendered on January 23, 2020.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment was applied 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 $125 copayment for each in-network Medicare-covered radiological diagnostic service, not including x-rays.
Review of the file shows that you received a duplex vein scan on January 23, 2020. You have been asked to pay a $125 copayment for these services. These services fall within the in-network Medicare-covered radiological diagnostic service, not including x-rays, benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the duplex vein scan rendered on January 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for skiing services on January 1, 2019.
You asked the Plan to pay for the services. You say that you are requesting reimbursement of services
rendered. The Plan denied your request. The Plan says skiing is not a covered benefit under the Wellness
Allowance benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
The Plan's rules for coverage of gym benefits have not been met because skiing is not a covered benefit under
the Wellness Allowance benefit. Therefore, we decided that the Plan does not have to pay for skiing services
on January 1, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided by a participating provider on February 7, 2020.
You asked the Plan to waive the copayment for an MRI. You say that you do not have the money to pay for this. The Plan denied your request. The Plan says the correct copayment 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 $300 copayment for outpatient diagnostic tests/diagnostic radiology. You have been asked to pay a $200 copayment for an MRI. An MRI falls within the outpatient diagnostic tests/diagnostic radiology benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an MRI provided by a participating provider on February 7, 2020.
We note your complaint about being unable to pay this due to COVID-19. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient physical therapy visits.
You asked the Plan to pre-approve physical therapy. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because the enrollee does not meet the Medicare criteria for the requested therapy services.
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 physical therapy. 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 generally accepted as a specific and effective therapy for the enrollee's condition. Goals include reducing spasticity-related pain, restoring function, and educating regarding a home exercise program prior to transition to a home program. In this case, there is no indication that prior physical therapy has served to provide sustained, significant improvement in pain and/or function and there are no residual deficits that could not be addressed by a home exercise program. Therefore, this request 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 physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve outpatient physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care can be provided in the current inpatient hospital.
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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound and skin care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the wound care services. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says this is non-emergent, routine wound care and there were network providers available to provide this service.
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 medical services provided on February 14, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for immunotherapy services provided by a
participating provider on February 29, 2020.
You asked the Plan to waive the copayment for immunotherapy services. You say that you were told there
would be no copayment. The Plan denied your request. The Plan says the correct copayment 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
copayment for physician/practitioner services/specialist.
You have been asked to pay $10.36 which is less than your copayment amount of $20 for immunotherapy
services. The services that were provided were provided by a specialist; therefore, the correct copayment has
been applied. Immunotherapy services fall within the physician/practitioner services/specialist benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for immunotherapy services provided by a participating
provider on February 29, 2020.