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

We decided that the Plan does not have to pre-approve Xgeva (J0897).You asked the Plan to pre-approve the Xgeva. You say that Xgeva is medically necessary for treatment of the member's condition.The Plan denied your request. The Plan says documentation was not received 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 looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Xgeva have not been met. Specifically, no medical records have been submitted to determine the medical necessity of a step therapy exception.Therefore, we decided that the Plan does not have to pre-approve Xgeva (J0897)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora Zoster (shingles) vaccine (90750) provided on November 15, 2019.You asked the Plan to pay fora shingles vaccine. You say that you did not know that this vaccine was not covered.The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of a prescription drug plan.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured ordirectly exposed to any illness related to a shingles vaccine.Therefore, we decided that the Plan does not have to pay fora Zoster (shingles) vaccine (90750) provided on November 15, 2019.Benefits for a shingles vaccinemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 12, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for office services. You say that authorization is not needed, and prior claims have
been paid without authorization. The Plan denied your request. The Plan says the denial of payment for these
services is correct, because this provider is out-of-network with the Plan and the services were not urgent or
emergent in nature.
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 September 12,
2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided on November 15, 2019.You asked the Plan to reduce the copayment forthe inpatient hospital care. You say that you received an outpatient shoulder replacement surgery. You say you would like the claim adjusted to the outpatient surgery code. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment per admission after the deductible is met. You have been asked to pay a $300 copayment for the inpatient hospital care. The inpatient hospital care falls within the "Inpatient hospital care" benefit category. The medical record shows that the shoulder replacement surgery is an inpatient procedure.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 reduce the copayment forthe inpatient hospital stay provided on November 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (64624 and 64625).You asked the Plan to pre-approve radiofrequency ablation. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee's pain is adequately controlled.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 radiofrequency ablation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/ investigational procedure that is the subject of on-going clinical trials. Therefore, it is not medically reasonable or 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 radiofrequency ablation have not been met.Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (64624 and 64625).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).You asked the Plan to pre-approve a portable oxygen concentrator. You say that you need the item in order to travel.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services (97810 and 97811) provided from September 12, 2019 to September 19, 2019.You asked the Plan to pay for acupuncture services. You say that this is a covered benefit.The Plan denied your request. The Plan says acupuncture is not covered by Medicare or the Plan. 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 pay for acupuncture services (97810 and 97811) provided from September 12, 2019 to September 19, 2019.
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 records provided support the need for IRF care The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval of IRF care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee's chronic medical conditions are all stable and there are no medical complexities which require IRF care. The enrollee's rehabilitation needs are at a lower intensity and could be provided in a skilled nursing facility (SNF) setting.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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a Cologuard screening test provided on November 4, 2019.
You asked the Plan to pay for Cologuard test. You say that this test should be fully covered by the Plan. The
Plan denied your request. The Plan says the denial of payment for this service is correct, because you received
the same test on June 22, 2017 and this test is only covered once every 3 years.
The Plan must follow Medicare rules. Medicare rules say that DNA colorectal cancer screening (Cologuard)
testing is covered once every 3 years for enrollees ages 50 to 85 years old.
We looked at the file and Medicare rules. A Cologuard test was provided to you on June 22, 2017, therefore 3
years had not passed before this test was performed. Based on this information, we decided that Medicare rules
for coverage of Cologuard test have not been met. Therefore, we decided that the Plan does not have to pay for
a Cologuard screening test provided on November 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary.The Plan denied your request. The Plan says the provider has not indicated that there will be a benefit from special long term acute care.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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory care with suctioning and pulmonary toilet, intravenous antibiotics, surveillance laboratory studies, hemodialysis, wound care, tube feedings, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 20, 2019 by an out of network (OON) provider.You asked the Plan to pay forphysician visit. You say that your provider cannot deny any medical services that were essential for the enrollee's treatment.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the referring provider is also out-of-network with the Plan.Medicare rules say that plans can require enrollees to get care from network providers. The contract withthe 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 medical services provided on September 20, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nutropin AQ.You asked the Plan to pre-approve the Nutropin AQ. You say that the records provided support the need for the drug being requested.The Plan denied your request. The Plan says this medication is covered under Part D benefit, and the enrollee does not have Part D benefits through the Plan.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 Nutropin AQ.Benefits for the Nutropin AQmay 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve filling for a crown with posts tooth 20 (D2950).You asked the Plan to pre-approve filling for a crown with posts. You say that you are requesting reconsideration of the denial of coverage.The Plan denied your request. The Plan says the requested service is not covered under the 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. Services and codes not listed under the Dental Benefits on pages 90-101 is not covered by the plan.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 filling for a crown with posts tooth 20 (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe periodic oral evaluation (D0120) and prophylaxis (D1110) provided on September 24, 2019.You asked the Plan to reimburse you forthe dental service. You say that the services should be reprocessed per your benefit.The Plan denied your request. The Plan says you were reimbursed for the amount of $150 towards your 2019 Dental Allowance for dental services you received on September 24, 2019. The Plan also says that the dental allowance 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.Though the Plan offers a dental benefit in excess of Medicare coverage, the $150 dental allowance has been exhausted.Therefore, we decided that the Plan does not have to reimburse you forthe periodic oral evaluation (D0120) and prophylaxis (D1110) provided on September 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs are still complex enough to require daily physician monitoring from multiple specialties. The Plan denied your request. The Plan says the enrollee's needs are being met in the current setting.

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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for chronic thigh wounds and dehydration. The enrollee has received antibiotics and continues to receive wound care. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.

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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea retreatment of a previous root canal therapy (D3346) for tooth # 11.You asked the Plan to pre-approvethe retreatment of a previous root canal therapy. You say that your tooth was shaved down and capped, then it broke. You also say that as a result, you have lost 20 pounds because you are unable to eat.The Plan denied your request. The Plan says the retreatment of previous root canal therapy 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 dental service is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea retreatment of a previous root canal therapy (D3346) for tooth # 11.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided on July 25, 2019. You asked the Plan to reimburse you for the dental service. You say that your plan covers basic cleaning services. You say that your plan does not cover periodontal services. You say that you should be reimburse for a normal cleaning. You also say that your coverage should be changed for next year so that any type of cleaning is covered instead of the artificial distinction between normal and periodontal cleaning.The Plan denied your request. The Plan says periodontal maintenance is not covered under any circumstance. The Plan also says you can contact customer service for more information about the supplemental Platinum Dental Rider and to enroll.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 applyin this case.Though the Plan offers a dental benefit in excess of Medicare coverage, periodontal maintenance is not among those covered under this benefit.Therefore, we decided that the Plan does not have to reimburse you forthe periodontal maintenance (D4910) provided on July 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on June 27, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 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 medical services provided to the enrollee by an out-of-network provider on June 27, 2019
Appeal type: Inpatient Hospital
Decision: Partially Favorable

We decided that the Plan has to pre-approve inpatient behavioral health the day of admission. We decided that
the Plan does not have to pre-approve inpatient behavioral health after the day of admission.
You asked the Plan to pre-approve inpatient behavioral health. You say that the services are necessary. The
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not
been met.
We decided that the Plan has to pre-approve inpatient behavioral health the day of admission. We asked our
physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the
Part C Plan was correct in denying the request to pre-approve inpatient behavioral health the day of admission.
Our reviewer says that the requested service is considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee did have auditory hallucinations but no visual hallucinations. The day of
admission the enrollee did meet the criteria for inpatient treatment.
Therefore, we decided that the Plan has to pre-approve inpatient behavioral health the day of admission.
We also decided that the Plan does not have to pre-approve inpatient behavioral health after the day of
admission. Our reviewer says that the requested service is not considered medically reasonable and necessary
in this case. Our physician reviewer found based upon review of the records provided, the admission of this
enrollee does not meet the criteria for acute inpatient mental health treatment the day after admission. This
enrollee was not shown to be a danger to himself or others the day after admission, was without agitation or
aggression and without visual hallucinations.
Therefore, we decided that the Plan does not have to pre-approve inpatient behavioral health after the day of
admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on November 4, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 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 medical services provided to the enrollee by an out-of-network provider
on November 4, 2019.