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

We decided that the Plan does not have to waive the cost-shares for the Urology office visit and Leuprolide acetate injection (99213, 96372, J9217) provided June 3, 2020.
You asked the Plan to waive the cost-shares for the Urology office visit and Leuprolide acetate injection. You say that you believe you were charged for out-of-network services and should not be responsible for the entire cost-share. The Plan denied your request. The Plan says the cost-sharing 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 $30 copayment for Physician/Practitioner services, provided in a specialist's office. The Plan contract also says that you must pay 20% coinsurance for Medicare Part B covered drugs. You have been asked to pay a total of $ 312.44 cost-sharing (($1,412.22 allowed amount x 20% coinsurance for the injection = $282.44) + $30 copayment for the office visit = $ 312.44). The office visit falls within the Physician/Practitioner services, including doctor's office visits benefit category. The injection falls within the Medicare Part B Prescription Drugs 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 cost-shares for the Urology office visit and Leuprolide acetate injection (99213, 96372, J9217) provided June 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. There is no documentation that the enrollee requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health services.
You asked the Plan to pre-approve continued home health services. You say that you need continued home health services to treat your wounds. The Plan denied your request. The Plan says home health care is no longer necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 continued home health services. Our reviewer says that continued home health services are not medically necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment to improve or maintain your condition. You have had extensive prior skilled nursing services. There is no evidence of complex wound care or other skilled nursing needs 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 continued home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on July 13, 2020.
You asked the Plan to waive the copayment for an emergency room visit. You say that you do not agree with this 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 $90 copayment for emergency care/in-network/emergency services. You have been asked to pay a $90 copayment for an emergency room visit. The correct copayment has been applied to the services that were provided. An emergency room visit falls within the emergency care/in-network/emergency services 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 emergency room visit provided by a participating provider on July 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Blepharoplasty, upper eyelid (15823) and Repair (Brow Ptosis, Blepharoptosis, Lid Retraction, Ectropion, Entropion) (67900) procedures.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no evidence of a potential for correction of your condition with the requested procedure.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Based on the upper eyelid elevation test, the documentation does not support that there is potential for correction of your visual fields with the requested procedures. Our physician reviewer found that your condition does not meet Medicare criteria for these services. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve Blepharoplasty, upper eyelid (15823) and Repair (Brow Ptosis, Blepharoptosis, Lid Retraction, Ectropion, Entropion) (67900) procedures
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.
You asked the Plan to pre-approve the services. You say that the enrollee was responsive to the diagnostic block. The Plan denied your request. The Plan says this is considered not medically necessary and investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental and investigational procedure because of the wide variation in efficacy reported in the literature. Therefore, the request is considered 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Yervoy and Opdivo.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.
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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has a diagnosis of metastatic Merkel cell carcinoma (MCC) of the left forearm. MCC is a rare, aggressive, cutaneous malignancy that predominantly affects older adults with light skin types and has a high propensity to metastasize. For those with advanced disease that has progressed through anti-PD-1 therapy, one retrospective case series reported the efficacy of ipilimumab alone or in combination with an anti-PD-1 agent. The enrollee had a short course of pembrolizumab in December of 2020 and has limited treatment options. The service is 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 these services have been met. Therefore, we decided that the Plan has to pre-approve Yervoy and Opdivo.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain fused to high metal crown rendered on June 10, 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 claim was processed correctly.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers crowns with a 35% coinsurance from an out-of-network provider. Review of the file shows that you received a crown from an out-of-network provider on June 10, 2020. The Plan has reimbursed you for these services, less the 35% coinsurance listed in the Plan contract. Further reimbursement is not covered by Medicare or your supplemental dental benefit. Therefore, we decided that the Plan does not have to pay for the porcelain fused to high metal crown rendered on June 10, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve onabotulinumtoxina injection.
You asked the Plan to pre-approve onabotulinumtoxina injection. You say that your doctor advised that this is the next step in the treatment of your migraines. You also say that you have tried and failed previous medications and treatments. The Plan denied your request. The Plan says that there is no documentation that shows you have more than 15 headaches a month for 3 or more months. The Plan also says that there is no documentation that shows you are not able to tolerate it for at least 3 months.
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 onabotulinumtoxina injection. Our reviewer says that the onabotulinumtoxina injection is medically necessary. Our physician reviewer found the documentation provided for review suggested that you were having migraines 20 to 30 days per month at baseline. The reviewer foudn that this is more than the minimum frequency of 15 per month required by the Local Coverage Determination (LCD) for coverage of Botox for the treatment of migraine headaches. The reviewer found that the drug is otherwise known to be safe and effective for use in the treatment of chronic migraines (as supported by its FDA approval for use in this indication and the support within current practice guidelines). Therefore, the reviewer found that in this setting, the requested therapy can be said to be 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 onabotulinumtoxina injection have been met. Therefore, we decided that the Plan has to pre-approve onabotulinumtoxina injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vacuum-assisted socket system (L5781) for a prosthetic leg for the enrollee.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says this does not meet criteria as reasonable and 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 the system. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the vacuum-assisted socket system (L5781) is not medically necessary and appears to exceed the enrollee's medical needs. The documentation does not reveal that the approved socket L5647 (Addition to lower extremity, below knee suction socket) does not meet the patient's needs. There are no objective physician progress notes indicating volume fluctuation or edema in the residual limb. 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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve a vacuum-assisted socket system (L5781) for a prosthetic leg for the enrollee.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee can safely receive the needed 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 in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a fall and complete
heart block. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs.
The patient does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically
necessary care can be provided in a different level of care. There is not a reasonable expectation that this
patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program
provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria
for IRF 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-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for endodontic therapy (D3330) limited oral exam (D0140) provided September 10, 2020.
You asked the Plan to waive the copayment for the dental services. You say that a root canal was done, and the plan should have paid 50% The Plan denied your request. The Plan says the benefit frequency limitation has been exceeded. The correct cost share was applied per the Evidence of Coverage.
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay 50% copayment for endodontic therapy. You may be billed more by an out of network provider if the charge is greater than the maximum allowable charge.
You have been asked to pay $1,091 ($1,006 + $85 = $1,091) for the dental services. D0140 is covered however this service is covered once a year. The records show this service was provided July 9, 2020 therefore the benefit is exhausted. The services fall within the Dental services 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 endodontic therapy (D3330) limited oral exam (D0140) provided September 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced foot feature for a prosthetic device.
You asked the Plan to pre-approve the advanced feature. You say that the enrollee has to walk on uneven terrain. The Plan denied your request. The Plan says the enrollee is not a K3 ambulator.
The Plan follows Medicare rules. Medicare rules say that Clinical assessments of beneficiary rehabilitation potential must be based on the classification levels.
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 advanced feature. Our physician reviewer found that per documentation the enrollee is a current K1 ambulator who has cane/crutches and wheelchair. He is expected to require use of cane and crutches with prosthesis as well as ramps. Normal daily activity is 80% seating and 20% standing. He lives on 2 acres and has a large garden that he uses a tractor on. He likes to garden. He has a garage where he works on his car and does woodwork. The documentation does not support that this enrollee requires the advanced foot and ankle K3 components. The documentation does not reveal that he has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. Therefore, the requested advanced foot feature is not medically reasonable and necessary for the enrollee's prosthesis.
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 advanced feature have not been met. Therefore, we decided that the Plan does not have to pre-approve an advanced foot feature for a prosthetic device.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation to a location that is more than 50 miles from your home address.
You asked the Plan to pre-approve the routine transportation services. You say that you need the extra mileage allotment in order to see your pain management doctor. The Plan denied your request. The Plan says the enrollee's request exceeds the benefit allowance.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one-way routine transportation trips that do not exceed 50 miles of driving distance. We looked at your request, the records in the case file, and the rules. The records show that the location you are requesting routine transportation to, exceeds 50 miles. Based on this information, we decided that your request is for routine transportation does not fit the guidelines which allow for coverage. Therefore, we decided that the Plan does not have to pre-approve routine transportation to a location that is more than 50 miles from your home address.
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 services are necessary. 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 say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical condition does not require intensive physician or nursing supervision in an IRF. The enrollee may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.