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

We decided that the Plan does not have to pre-approve Repatha.
You asked the Plan to pre-approve Repatha. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the requested drug is not medically necessary.
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 Repatha.
Benefits for Repatha may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on January
10, 2020.
You asked the Plan to pay for the shoulder-elbow-wrist-hand orthosis (L3960). You say that the Plan should
pay this claim. The Plan denied your request. The Plan says the documentation submitted did not indicate the
provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. The medical records do not mention or support medical necessity for
the orthosis. Based on this information, we decided that Medicare rules for coverage of the shoulder-elbowwrist-
hand orthosis (L3960) have not been met. Therefore, we decided that the Plan does not have to pay for
the shoulder-elbow-wrist-hand orthosis provided on January 10, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 38 additional visits to continue care with an out-of-network Psychologist.
You asked the Plan to pre-approve continued care with an out-of-network provider. You say that the requested continued care beyond the 2 approved visits with the out of network psychologist is medically necessary. The Plan denied your request. The Plan says the requested continued care with the out of network psychologist is not medically necessary.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 care with an out-of-network provider. Our reviewer says that the requested continued care with the out of network psychologist is not medically necessary. Our physician reviewer found this enrollee is being treated for Depression and Generalized Anxiety. Based on review of the records provided, it is noted that this enrollee had chronic suicidal thinking without intent for action, sadness, loneliness, mental disorganization, poor eating habits, fatigue,
feelings of worthlessness, poor concentration, indecisiveness, and chronic social and generalized anxiety. The enrollee has been seeing the therapist off and on since 2011. The treatment plan from the provider stated that despite efforts to improve symptoms and coping skills with an increased intensity of treatment, the enrollee reports that mental health symptoms continue to prove chronic and have not responded significantly to treatment. Based on review of the records provided this enrollee's request for additional treatment sessions does not appear to show through documentation of this enrollee improvement or worsening with therapy rendered therefore it does not appear to be reasonable or medically necessary. This enrollee does not require treatment by an out-of-network provider as this enrollee is being treated for depression which is not considered an emergent condition. The provider indicated there was no concern for risk. There is an in network provider located in his area which is accepting new patients. This enrollee does not meet the condition of being in an urgent/emergent condition and can safely be seen by an in network therapist who is credentialed and maintained by the medical plan. 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 care with an out-of-network provider have not been met. Therefore, we decided that the Plan does not have to pre-approve 38 additional visits to continue care with an out-of-network Psychologist.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from December
27, 2019 through December 31, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You say that this was an emergency service.
You say that you shouldn't be charged a copayment. The Plan denied your request. The Plan says the
copayment 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 $250 per
day, days 1-7 for each in-network, Medicare-covered hospital admission/stay .
You have been asked to pay $956.85, which is less than the standard copayment for the inpatient stay because
you met your maximum out-of-pocket. The inpatient 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 for the inpatient stay provided from December 27,
2019 through December 31, 2019.
Appeal type: Lab
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 December 11, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network
deficiency for these 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 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 December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided September 19, 2019 to December 12, 2019.
You asked the Plan to pay for the chiropractic services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says this service is not payable.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. Review of the file shows that the claim was not billed with the AT modifier. Claims without the AT modifier are considered maintenance therapy. Maintenance therapy is not a covered benefit. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided September 19, 2019 to December 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis, bitewings, comprehensive oral evaluation,
and panoramic x-ray provided by an OON dentist on January 3, 2020.
You asked the Plan to pay for the prophylaxis, bitewings, comprehensive oral evaluation, and panoramic x-ray.
You say that a plan representative told you that this provider was in-network with your plan. The Plan denied
your request. The Plan says the treating provider is not participating with your plan. The Plan also says that
there were no calls to the Plan prior to the services being rendered to check the provider's network status.
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
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the
prophylaxis, bitewings, comprehensive oral evaluation, and panoramic x-ray provided by an OON dentist on
January 3, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea.
You asked the Plan to pre-approve Eylea. You say that the requested Eylea is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Avastin 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 Eylea. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is with wet age-related macular degeneration with neovascularization in the right eye. He has been receiving Avastin injections in the right eye and the latest office visit note reports his condition "appears stabilized." The provided medical records do indicate that the enrollee has been receiving the required drug with report that his condition appears stabilized. Exact details of how the Avastin is no longer felt to be effective for the enrollee's condition are not provided in the available medical records. The provided medical records do not provide specific details as to how the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to pre-approve Eylea.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Herceptin (Trastuzumab).
You asked the Plan to pre-approve the Herceptin (Trastuzumab). You say that the enrollee was approved to
receive Trastuzumab with standard of care chemotherapy infusions from February 13, 2020 to May 8, 2020 due
to being HER-2 receptor positive and having a stave intravenous uterine serous carcinoma. You also say that
once the enrollee completed standard of care chemotherapy, she was to transition to Trastuzumab maintenance
until recurrence or progression of disease which was allowed in the phase 2 trial for which it was studied. The
Plan denied your request. The Plan says the compendia does not support this drug/regimen to treat your
specific cancer-Stage IIIC1, HER2+ endometrial cancer.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Herceptin (Trastuzumab). Our
reviewer says that the Herceptin (Trastuzumab) is not medically necessary. Our physician reviewer found the
requested use of Herceptin (Trastuzumab) is not FDA-approved for the enrollee's diagnosis. Our reviewer
found that this request is off-evidence, in which therapy is requested for an off-label use that is not supported
by drug compendia or peer reviewed literature from a journal eligible for coverage. There is no data to support
the safety and/or efficacy of this regimen as requested. Our physician reviewer also found that the off-evidence
use of this therapy does not meet the criteria for being 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 the Herceptin (Trastuzumab) have not been met. Therefore, we decided that the
Plan does not have to pre-approve Herceptin (Trastuzumab).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits provided on January 27, 2020 and January 28, 2020.
You asked the Plan to waive the copayments for specialist visits. You say that you were admitted inpatient and should not be responsible for the charges. 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 $35 copayment for each specialist visit. The medical records show that you received specialist visits on January 27, 2020 and January 28, 2020 during an outpatient hospital stay. Therefore, you are responsible to pay a $35 copayment per each visit. The total amount you owe is: $70. You have been asked to pay the total copayment amount of $70 for specialist visits. Specialist visits fall 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 copayments for specialist visits provided on January 27, 2020 and January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the deductible for the outpatient vision services provided on
December 31, 2019.
You asked the Plan to reduce the deductible for the outpatient vision services. You say that you would like this
visit to be considered an emergency room visit. 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. Your
contract with the Plan says that there is a $950 deductible that applies towards out-of-network outpatient vision
services.
The outpatient vision services you asked the Plan to reduce the deductible for falls within the "Outpatient
hospital services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract
that there is a $950 deductible that applies towards out-of-network outpatient vision services. This cost sharing
is a contractual obligation that had not been met at the time the outpatient vision services was received on
December 31, 2019. Therefore, we decided that the Plan does not have to reduce the deductible for the
outpatient vision services provided on December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nerve conduction studies (95911) and needle electromyography (95886) provided on December 17, 2019 by an out of network (OON) provider.
You asked the Plan to pay for OON nerve conduction studies and needle electromyography. You say that these services were medically necessary. The Plan denied your request. The Plan says these 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 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 nerve conduction studies (95911) and needle electromyography (95886) provided on December 17, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of complications (post-surgical) - unusual
circumstances provided on January 16, 2020.
You asked the Plan to pay for the treatment of complications. You say that this service was provided after an
extraction that got complicated and you were in pain. The Plan denied your request. The Plan says this service
is not covered.
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 pay for the
treatment of complications (post-surgical) - unusual circumstances provided on January 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic shoes and inserts.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says you do have diabetes, but you do not have a covered at-risk foot condition.
The Plan must follow Medicare rules. Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 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 according to the enclosed information, you are noted to be diabetic, and suffering with painful plantar fasciitis. The physical examination noted on 2/3/2020 advises of intact neurovascular status with essentially a pes planus foot structure, valgus right heel, and a tight plantar fascia bilaterally. During this visit, it was recommended that you receive diabetic shoes and diabetic inserts. Guidelines pertinent to this case advise that in order for a patient to receive diabetic shoes and inserts the patient must be diabetic. The patient must also demonstrate one or more of the following conditions: peripheral neuropathy with evidence of callous formation, history of a pre-ulcerative callous, history of previous ulceration, foot deformity, previous amputation of the foot or part of the foot, or poor circulation. The medical documentation in this chart does not support that you are suffering from any of the above pathologies that would allow for authorization of diabetic shoes with diabetic insoles.
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 diabetic shoes and inserts.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for hand wrist orthosis (L3916) provided on January 13, 2020.
You asked the Plan to pay for the hand wrist orthosis. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the documentation submitted did not indicate
the provider discussed the need for the billed supply code.
The Plan must follow Medicare rules. Medicare rules say that for any DMEPOS item to be covered by
Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition
to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or
replacement (if applicable).
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the hand wrist orthosis have not been met. Specifically, the record indicates that the Plan requested
progress notes by the ordering physician along with documentation of the duration of the member's condition,
clinical course (worsening or improving), prognosis, nature and extend of functional limitations, other
therapeutic interventions and results and previously purchased DME items related to the billed items. There is
insufficient information to verify the billed supply code. Therefore, we decided that the Plan does not have to
pay for hand wrist orthosis (L3916) provided on January 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electric wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that you get extremely tired and you have trouble standing up. The Plan denied your request. The Plan says there is no assessment of mobility limitation with respect to your ability to participate in or more ADLs.
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. 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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found there is no noted inability to use a lesser device (lightweight manual wheelchair, standard manual wheelchair, or use of a walker). Therefore, this request is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve an electric wheelchair.