Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve a power wheelchair. You say that you want to get out independently to the store or a restaurant without your caregiver. The Plan denied your request. The Plan says based on your home evaluation you are able to do your daily self-care activities with the use of a four-wheeled walker and/or manual wheelchair.
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 file shows that your condition can be improved by a walker. Neither Medicare nor the Plan cover PMDs for use only outside the home. 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 power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee is with a history of diabetes, past transient ischemic attack and atrial fibrillation who was admitted to an acute care hospital on 02/23/2020 with a gastrointestinal hemorrhage. She had chest pain associated with severe anemia (Hemoglobin 4.3/Hematocrit 17.9). An endoscopy showed a bleeding duodenal ulcer and esophageal ulcers. She had surgery for the bleeding duodenal ulcer and has been treated with intravenous pantoprazole, multiple red blood cell transfusions and intravenous iron. She had an exercise stress test and a cardiology evaluation showing no ischemia. She has had atrial fibrillation with rapid ventricular response treated with intravenous Cardizem and she has had intravenous antibiotics. She is getting total parenteral nutrition. She is weak and deconditioned and requires physical and occupationaltherapy as well as wound care.Based on the provided medical records the acute care hospital is able to provide all of the services the enrollee requires. Based on the provided medical records the enrollee is receiving necessary services and is at an appropriate level of care in the acute care hospital. Based on the provided medical records the enrollee is receiving these services in the present acute care hospital. Continued care at this level is appropriate until the enrollee is stable to transfer to a lower level of 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have topre-approvelong term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the brain for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says there are other recommended tests for memory changes that should be done first.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found although the necessary labs have been discussed and apparently ordered the results are not in the submitted records. These lab results are necessary in order to validate medical necessity for brain MRI especially since long and short term memory have been described as normal although no quantitative testing is in the records. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the brain for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on
September 10, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you cannot afford to pay
for this. The Plan denied your request. The Plan says that the cost-share 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 $195
copayment for each one-way Medicare-covered ground trip.
You have been asked to pay a $195 copayment for the ambulance transport. The ambulance transport falls
within the one-way Medicare-covered ground trip 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 ambulance transport provided on September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on October 17, 2019.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because the drain did not work for you. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $50 copayment per specialist visit. You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 a specialist visit provided on October 17, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services.
You asked the Plan to pre-approve the physical therapy. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services for surgery to be provided by "the doctor".You asked the Plan to pre-approve the physician's services.The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services for surgery to be provided by "the doctor".
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan.
You asked the Plan to pre-approve Rituxan. You say that the requested Rituxan is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Truxima or Ruxience first.
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 Rituxan. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has a diagnosis of follicular lymphoma grade II, lymph nodes of multiple sites. The Plan requires a trial of drugs Truxima or Ruxience first before they will approve the requested drug, Rituxan. The documentation does not support that the enrollee has tried and failed the Plan's preferred drugs. The documentation does not support that the biosimilars Truxima (Rituximab-abbs) and/or Ruxience (Rituximab-pvvr) 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 Rituxan have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituxan.
Appeal type: Drugs
Decision: Favorable

We decided that the Planhasto pre-approvelumbar and sacral epidural injections.You asked the Planto pre-approvethe injection. You say that this is medically necessary, as you have tried physical therapy and you are hardly able to walk.The Plandenied your request. The Plansaysthatthere are no recent physical therapy notes, nor other conservative therapy treatment documented otherthan Diclofenac.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found you have failed conservative therapy, and the pain generators are documented on MRI. The requested procedure is medically reasonable and 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 the injection have been met.Therefore, we decided that the Planhas to pre-approvelumbar and sacral epidural injections. If the Plandoes not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. 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.
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer found the enrollee has therapy and medical needs that meet criteria for acute level rehabilitation. Care at a lower level would not effectively meet the enrollee's rehabilitation needs. 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 been met. Therefore, we decided that the Plan has 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 the drug testing services provided to the enrollee on April 3, 2019.

You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. 

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on April 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 16, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for specialist office visits, minor surgery, and
chemotherapy administration provided from September 23, 2019 to November 24, 2019.
You asked the Plan to waive the cost sharing for specialist office visits, minor surgery, and chemotherapy
administration. You say that you do not agree with these charges. The Plan denied your request. The Plan says
these services processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 15% of
the total cost for Medicare-covered chemotherapy drugs, a $150 copayment for Medicare-covered outpatient
surgery, and a $25 copayment per visit for Medicare-covered specialty care.
You have been asked to pay $25 for each specialist office visit, $150 for minor surgery, and 15% of the
allowed amounts for chemotherapy administration. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing for
specialist office visits, minor surgery, and chemotherapy administration provided from September 23, 2019 to
November 24, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on November 4, 2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that you thought this was a regular colonoscopy that would be covered under insurance. You say you were not expecting a $300 bill. 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 for an Outpatient Hospital Facility. You have been asked to pay a $300 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical center" benefit category. The medical record shows you had a polyp removed.
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 colonoscopy provided on November 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.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 rulesto determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to an acute care hospital on 3/3/20 for progressively worsening dyspnea on exertion with subsequent cardiac workup revealing severe multi-vessel disease. Therapy notes dated 3/10/20 indicate that he requires minimal to moderate assist for activities of daily living and moderate assist for lower body dressing. The enrollee needed supervision to standby assist for toileting. The enrollee needed standby assist for transfers and ambulation using a wheeled walker. Based on review of available records, the enrollee does not meet criteria for coverage for an IRF admission. The enrollee is generally medically stable post coronary artery bypass graft and debility from the cardiac disease with no recent neurological or Orthopedic events and there is no evidence of complex medical issues that requiremonitoring by an inpatient physical medicine and rehab physician three times per week or need for acute rehab nursing care. While he may benefit from continuing physical therapy and occupational therapy, 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 Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Vascepa 1gm capsule medication.You asked the Plan to pre-approvethis medication. You say that this medication is medically necessary for the enrollee.The Plan denied your request. The Plan says this medication is not a covered benefit under the enrollee's contractual policy.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approvethe Vascepa 1gm capsule medication.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for podiatry visit. You say that your physician rendered service and should be compensated. 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 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 for the medical services provided on October 14, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone graft (21210), extractions (41899), and an unlisted maxillofacial prosthetic procedure (21089).
You asked the Plan to pre-approve a bone graft, extractions, and an unlisted maxillofacial prosthetic procedure. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 bone graft (21210), extractions (41899), and an unlisted maxillofacial prosthetic procedure (21089).