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

We decided that the Plan does not have to pre-approve a CPAP full face mask and CPAP face mask interface.You asked the Plan to pre-approve a CPAP full face mask and CPAP face mask interface. You say that the enrollee needs the mask and interface.The Plan denied your request. The Plan says there is no current information pertaining to medical necessity of a CPAP device.The Plan must follow Medicare rules. Medicare rules say that for any item to be covered by Medicate it must meet all applicable Medicare statutory and regulatory requirements.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CPAP full face maskand CPAP face mask interface have not been met.Therefore, we decided that the Plan does not have to pre-approvea CPAP full face mask and CPAP face mask interface.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from July 16, 2019 through July 17, 2019.You asked the Plan to pay forthese drugs. You say that all the medications ordered were required for your medical conditions.The Plan denied your request. The Plan says that these drugs are not covered under Part B.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 pay forthe self-administered drugs provided from July 16, 2019 through July 17, 2019.Benefits for these drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from August 14, 2018 through August 17, 2018.You asked the Plan to waive the copayment forinpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plansays the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on August 14, 2018 and discharged on August 17, 2018. You were asked to pay a $250 copayment per day from August 14, 2018 through August 16, 2018, days 1-3 of your inpatient hospital care. You were discharged on August 17, 2018 andthere was no copayment charge for the day of discharge. Per your contract there is a $250 copayment per day required for days 1-7. 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 forinpatient hospital care provided from August 14, 2018 through August 17, 2018.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe non-emergency ambulance service provided on March 24, 2019 by out of network provider.You asked the Plan to pay forthe ambulance service. You say that the reimbursement of this claim in the amount of $0 is not acceptable. This is the enrollee's primary insurance and this was a medically necessary transport.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 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 non-emergency ambulance service provided on March 24, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services provided on April 12, 2019 and April 18, 2019.You asked the Plan to pay forthe ophthalmological services. You say that the patient has emergency benefits and the medical recordsweresent to prove this was an emergencysituation. You say that iridocyclitis is a conditionthat causes great pain and should be considered an emergency.The Plan denied your request.The Plan requires utilization of network providerswhen possible and available and requires authorization for certain services.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 Plandid not pre-approve theservicesat 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 forophthalmological services provided on April 12, 2019 and April 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for blood vessel repair services (CPT 35256) provided on June 19, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says the records do not support the service billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 35256 is "Repair blood vessel with vein graft; lower extremity."We asked our coding 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 pay for the services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found CPT code 35256 is not supported by the medical record. The documentation does not contain evidence that a blood vessel of the lower extremity was repaired during this encounter.We looked at this coder'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 pay forblood vessel repair services (CPT 35256) provided on June 19, 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 you need rehabilitation services and your doctors told you that your condition qualifies you for an IRF admission.The Plan denied your request. The Plan says IRF care is not medically necessary at this time because the documentation received fails to indicate that the enrollee meets the criteria for coverage.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 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 documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit from and participate in additional physical therapy and occupational therapy, but does not require this on an intensive rehabilitation facility therapy program 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-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forthe anesthesia services rendered to the enrollee by "the provider" on March 21, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says that the services are not covered.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The documentation submitted by the Plan does not provide a clear denial reason for the services at issue. There are no Medicare rules or explanation of the Plan's denial reason.Therefore, we decided that the Plan has to pay forthe anesthesia services rendered to "the enrollee" by "the provider" on March 21, 2019.If the Plan does 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/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan doesnot have to pre-approveYutiq.You asked the Plan to pre-approveYutiq. The Plan denied your request. The Plan says that Ozurdex is the preferred drug.Medicare covers Part B medications when they are reasonable and necessary but allows healthplans 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 Yutiq. Our reviewer says that Yutiq is not medically reasonable and necessary in this case. You have been receiving Ozurdex injections and your condition adequately treated and controlled by this medication. You have not failed treatment with Ozurdex.Our physician reviewer found that your condition does not meet step therapy criteria for Yutiq. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Yutiq have not been met.Therefore, we decided that the Plan does not have to pre-approveYutiq
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve28 fractions of proton beam therapy.You asked the Plan to pre-approve28 fractions of proton beam therapy. You say that this is medically necessary.The Plan denied your request. The Plan says proton beam therapy has not been proven to be more effective than other radiotherapy modalities.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 28 fractions of proton beam therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found to date, there is no compelling data to suggest that proton therapy is superior to or more beneficial than other radiotherapy modalities. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 28 fractions of proton beam therapy have not been met.Therefore, we decided that the Plandoes not have to pre-approve28 fractions of proton beam therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesterile water/saline (A4216).You asked the Plan to pre-approvesterile water/saline. You say that this has put your health in danger. You do not feel that this is right and now you will be out of dressing.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. The rules say that the saline is non-covered because it does not meet the statutory definition of a surgical dressing.Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Based on this information, we decided that Medicare rules for coverage of sterile water/saline have not been met.Therefore, we decided that the Plan does not have to pre-approvesterile water/saline (A4216).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay provided on October 1, 2019 to October 2, 2019.You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you are on a fixed income and cannot afford 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 inpatient hospital care. You have been asked to pay a $300 copayment for an inpatient hospital stay. The correct copayment has been applied for the service that was provided. An inpatient hospital stay falls within the inpatient hospital care 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 foran inpatient hospital stay provided on October 1, 2019 to October 2, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora chest x-ray (71046) provided on September 26, 2019.You asked the Plan to waive the copayment for an x-ray. You say that you do not feel liable for the services because your doctor didn't have an x-ray machine and you had to go to the hospital for this service.The Plan denied your request. The Plan says outpatient diagnostic tests have a $50 copayment which includes x-rays.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 for outpatient diagnostic tests. You have been asked to pay a $50 copayment for an x-ray. This servicefalls within the outpatient diagnostic tests benefit category. You had x-ray services rendered at a hospital facility. 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 enrolledin the Plan.Therefore, we decided that the Plan does not have to waive the copayment fora chest x-ray (71046) provided on September 26, 2019
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveZarxio for the enrollee. You asked the Plan to pre-approveZarxio. The Plan denied your request. The Plan says the enrollee has not received previous treatment within the past 12 months, or an intolerance to Neupogen and Nivestym.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 requestto pre-approve Zarxio. Our physician reviewer found that the enrollee has a diagnosis of Malignant neoplasm of the descending colon. The enrollee has recurrent colon cancer, stage IV, with metastatic disease to the liver. She has a history of neutropenia after chemotherapy. The Plan requires a trial of Neupogen, Nivestym before they will approve the requested drug. The documentation does not show that the enrollee has tried and failed the required drugs. The documentation does not support that Neupogen and Nivestym 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 Zarixio have not been met.Therefore, we decided that the Plan does not have to pre-approveZarxio for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance forthe Part B injection provided on August 23, 2019.You asked the Plan to reduce the coinsurance forthe Part B injection. You say that you should only be charged a $100 copayment for the injection. 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 20% coinsurance for each Medicare-covered Part B drug. You have been asked to pay $229.20 which is 20% of the allowed amount for the Part B injection. The allowed amount is $1,146. ($1,146 x 20% = $229.20). The Part B 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 reduce the coinsurance forthe Part B injection provided on August 23, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute IRF admission and services.You asked the Plan to pre-approve IRF care. You say that the enrollee needs inpatient rehab to return home and become independent again.The Plan denied your request. The Plan says that the enrollee does not require full time access to a rehab doctor, or any specialized equipment.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee isstatus-post cerebellar stroke as described above and has physical impairments affecting mobility and remaining activities of daily living. The enrolleerequires oversight of his medical conditions. He is at risk for further strokes as well as hemorrhagic transformation. Herequires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. He requires assistance with essential activities of daily living and is ambulating less than household distances and requires an intensive rehabilitation therapy program. The enrollee'smedical conditions appear stable and he does not have cognitive impairment that would be expected to limit his ability to participate in as well as benefit from the required intensity of an acute rehabilitation therapy program. He had previously been able to function at a modified independent level and appears to have been working.The enrolleehas therapy and medical needs that meet criteria for acute level rehabilitation. Care at a lower level would not effectively meet this 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.You asked the Plan to pre-approve SNF services. You say that skilled nursing is needed to be released home safely.The Plan denied your request. The Plan says that there is no clear benefit of inpatient skilled nursing as opposed to an alternative setting for care.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLivalo.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says self-administered drugs are not covered.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-approveLivalo.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights