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

We decided that the Plan does not have to pre-approve Injectafer.
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 the services are not medically necessary.
The Plan must follow Medicare rules. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is noted to have a history
of iron deficiency anemia. Recent laboratory studies show a normal iron level, but a low transferrin saturation,
despite reported use of high dose oral iron. The health plan requires that other forms of IV iron be used first.
There is no evidence that the enrollee is allergic to or intolerant of these other forms of IV iron. There is no
evidence that the enrollee has tried and not responded to these other forms of IV iron. There is no
documentation as to why these other forms of IV iron would not be expected to be safe and effective for the
enrollee. Therefore, the requested Injectafer is not shown to be currently medically necessary and reasonable.
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 Injectafer.
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 would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medically necessary.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 you required minimal assistance for bed mobility. You required supervision for transfers and focusing on mobility with noted fatigue. The documentation does not support that you require monitoring by an inpatient physical medicine and rehabilitation physician three times per week or need for acute rehab nursing care. While you may benefit from further physical therapy and occupational therapy, there is no evidence for the need of 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 decidedthat 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that on the date of service you were at your dentist's office when you briefly passed out. An ambulance was called and the responders evaluated you upon their arrival. You say that they wanted to take you to the emergency room but you declined and instead went to see your personal doctor the following day. You stated that if you had decided to go to the hospital it would have cost the Plan thousands of dollars more. You say that it does not seem fair and you asked the Plan to reconsider paying for the ambulance bill. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 24, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for Procrit injection (HCPCS J0885) provided to the enrollee on February
13, 2020.
You asked the Plan to pay for the injection. You say that you have corrected the claim and removed the iron
deficiency anemia diagnosis. The Plan denied your request. The Plan says that standard systems maintainers
shall deny non-ESRD ESA services for HCPCS J0881 or J0885 billed with modifier -EC when any of the noncovered
diagnosis codes are present on the claim.
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. A review of the file shows that the provider used modifier -EC on the claim. The
Local Coverage Article that is valid for this case allows the use of modifier EC. It is unclear what statute the
plan is citing from to make their denial. The plan has not substantiated their denial. Therefore, we decided that
the Plan has to pay for Procrit injection (HCPCS J0885) provided to the enrollee on February 13, 2020.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided January 3, 2020 to January 4, 2020.You asked the Plan to pay for the acute inpatient hospital care. You say that the acute inpatient hospital care provided was medically necessary for the enrollee.The Plan denied your request. The Plan says the inpatient hospital admission was not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 pay for the acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee was out of town, traveling to see relatives when he presented to an outpatient clinic with ecchymosis over his right upper hip extending from the buttock to the lateral thigh. Chronic discoloration of the bilateral lower extremities was noted. He denied rectal bleeding, vomiting blood or hematuria. There were no recent falls or known trauma. The enrolleedid report that he bruised easily. The enrollee's wife stated the bruising had increased in size over the past two days. The enrollee had been traveling and felt he took the incorrect doses of Warfarin for the past week. He was admitted to inpatient care, the Warfarin and aspirin were held. There was no sign of active bleeding. The enrollee was subsequently discharged home on January 4, 2020 without incident. The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 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 acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided January 3, 2020 to January 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox (J0585).
You asked the Plan to pre-approve Botox. You say that this is medically necessary. The Plan denied your
request. The Plan says Botox is not supported for the enrollee's condition.
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 Botox. Our reviewer says that the
criteria for coverage of Botox has not been met. Our physician reviewer found the enrollee's diagnosis,
trigeminal neuralgia, is not one for which the requested medication is supported for use within the applicable
LCD or the Medicare accepted Compendia. The literature on the use of Botox in trigeminal neuralgia suggests
a potential benefit from the use of this therapy, but at the same time, publications also express a degree of
caution with use of the therapy. Most of the studies of Botox in the member's condition have had
methodological limitations (small sample sizes and short evaluation periods), which preclude reaching
conclusions on the overall utilty of the therapy. There otherwise remains a need for higher quality evidence to
support the use of Botox in this condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to
pre-approve Botox (J0585).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on November 8,
2019.
You asked the Plan to waive the deductible for the office visit. You say that the Plan has not paid their portion
for the provided service. 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 $110 deductible that applies towards office visits.
The office visit you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services,
including doctor's office visits" benefit category services. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is a $110 deductible that applies towards office visits. This cost sharing is a
contractual obligation that had not been met at the time the office visit was received on November 8, 2019.
Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on
November 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided
January 23, 2020 to January 30, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost sharing has been applied correctly to the services provided.
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 $350 copayment per day, for days 1-5 and a $0 copayment after day 5, for inpatient hospital care. You have been asked to pay a $1,750 copayment ($350 x 5 days) for inpatient hospital care. 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 hospital care provided January 23, 2020 to January 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport provided on February
12, 2020.
You asked the Plan to waive the copay for the ambulance transport. You say that the charge for the ambulance
ride is obscene. The Plan denied your request. The Plan says that the claim 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 a $275
copay for each Medicare-covered one-way trip via ground ambulance.
You have been asked to pay a $275 copay for the ambulance transport. The ambulance transport falls within
the Medicare-covered one-way trip via ground ambulance 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 copay for the ambulance transport provided on February 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the prosthetic services to be provided by an out of
network provider.
You asked the Plan to pre-approve prosthetic services with an out of network provider. You say that you have
special needs and the network providers have insufficient hours. The Plan denied your request. The Plan says
there are multiple network providers within 30 miles of your home able to perform the 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 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 the
prosthetic services to be provided by an out of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the occupational therapy visit provided on February 17, 2020.
You asked the Plan to waive the copayment for the occupational therapy visit. You say that you would not have a copayment. 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 $30 copayment for each Medicare-covered occupational therapy visit. You have been asked to pay a $30 copayment for the occupational therapy visit. The occupational therapy visit falls within the "Outpatient rehabilitation 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 the occupational therapy visit provided on February 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea backup battery for your CPAP machine.You asked the Plan to pre-approvea backup battery. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvea backup battery for your CPAP machine.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve authorization for services with an out-of-network provider.You asked the Plan to pre-approve authorization for services with an out-of-network provider. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says that they were unable to make a determination within the allotted time frame.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 Plan originally denied authorization for services with an out-of-network provider stating that the enrollee must see a doctor that is in your primary care doctor's referral network.The Plan was unable to make a final determination with the allotted time frame. The Plan has not provided a complete case file in regards to the request for services with an out-of-network provider. The Plan has not addressed if there is a continuity of care concern. The Plan has not provided any network provider names to show that network providers are both available and accessible to the enrollee. The Plan made no attempts to obtain medical records to determine medical necessity if there was a continuity of care concern. We find that the Plan has not provided enough information to substantiate their reasoning for denial.Therefore, we decided that the Plan has to pre-approve authorization for services with an out-of-network provider.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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for PET (78815) provided on December 26, 2019.
You asked the Plan to pay for the PET. You say that you would like reconsideration because this service was billed with an appropriate diagnosis code. The Plan denied your request. The Plan says the diagnosis code billed is not listed as an appropriate diagnosis.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 78815 is not supported in the record. Specifically, per the Medicare Claims Processing Manual, Chapter 13, 60.16, diagnosis code C25.9 is not an appropriate code for PET. Based on this information, we decided that Medicare rules for coverage of the PET have not been met. Therefore, we decided that the Plan does not have to pay for PET (78815) provided on December 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forvision services provided on March 2, 2020 by an out of network (OON) provider.You asked the Plan to pay forvision services. You say that this visit should be covered.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exceptionthat would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forvision services provided on March 2, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an 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 above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is medically stable with no evidence of a need for supervision by a physical medicine and rehabilitation physician or a need for acute rehabilitation nursing care. The enrollee may benefit from further physical and occupational therapy but does not require an intensive therapy program. The enrollee's rehabilitation needs can be met at a lower intensity setting such as in a skilled nursing facility. An IRF admission is not medically necessary based on the enrollee's current functional status and medical stability. 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 an acute inpatient rehabilitation facility (IRF) admission and services.