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

We decided that the Plan does not have to pre-approve Eliquis for the enrollee.
You asked the Plan to pre-approve Eliquis. You say that the enrollee has been stable on this medication. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.
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 Eliquis for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine you received on August 8, 2019.
You asked the Plan to pay for the shingles vaccine. You say that you cannot take the chance of coming down with shingles. The Plan denied your request. The Plan says this is not a covered service under your medical plan benefits.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on August 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride provided on August 8, 2019.
You asked the Plan to pay for the topical application of fluoride. You say that you are trying to care for your teeth the best you can. You also say that you needed the fluoride treatment so you do not lose any more teeth. The Plan denied your request. The Plan says this service is not covered under the Plan's supplemental benefits.
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 topical application of fluoride provided on August 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 6, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 6, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the spine.
You asked the Plan to pre-approve MRI. You say that you had spine surgery over 20 years ago and your doctor is requesting this test to see if there have been changes. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there has not been a substantial change in your signs or symptoms and surgery has not been performed since your previous study was performed.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve MRI. Our reviewer says that you do not meet the Medicare criteria for the requested MRI. Our physician reviewer found there is no documented change in your neurologic status and no red flags are present. Therefore, the requested MRI is 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the spine.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional SNF services.
You asked the Plan to pre-approve the additional SNF services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service is a covered benefit, but the enrollee has exceeded the limits set in the subscriber agreement.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from July 17, 2019 through January 8, 2020. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when they have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pre-approve additional SNF services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided to the enrollee on June 18, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided to the enrollee on June 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the enrollee is stable and no longer requires an inpatient level of care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found that LTACHs are certified as acute care hospitals, and in general, do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include oxygen supplementation, neurologic monitoring, seizure precautions, surveillance laboratory studies, fluid balance, tube feedings, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurane for the Regadenoson injection provided on August 15, 2019.
You asked the Plan to waive the coinsurance for the injection. You say that this should be considered part of your copayment for your scan. The Plan denied your request. The Plan says that you are responsible for the coinsurance 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 Medicare Part B prescription drugs. You have been asked to pay 20% coinsurance for the injection. 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 coinsurane for the Regadenoson injection provided on August 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 10, 2019 by an out of network provider.
You asked the Plan to pay for vision care services. You say that you want to know why you are being charged and why the doctor's office didn't tell you that your insurance didn't cover the services you received. The Plan denied your request. The Plan says prior authorization was not obtained for the services in question.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on September 10, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an Annual Wellness Visit provided on July 25, 2019.
You asked the Plan to pay for Annual Wellness Visit. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the enrollee has a prior Annual Wellness Visit on November 8, 2018 and therefore this visit exceeds the limit for this benefit.
The Plan must follow Medicare rules. Medicare rules say that an Annual Wellness visit is only covered once every 12 months. We looked at the file and Medicare rules. A prior Annual Wellness Visit was provided to the enrollee on November 8, 2018, therefore 12 months had not passed before this visit was provided. Based on this information, we decided that Medicare rules for coverage of Annual Wellness Visit have not been met. Therefore, we decided that the Plan does not have to pay for an Annual Wellness Visit provided on July 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intermittent limb compression device.
You asked the Plan to pre-approve intermittent limb compression device. You say that the requested device is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of the requested pump.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. 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 intermittent limb compression device. Our reviewer says that the requested device is not medically reasonable and necessary. Our physician reviewer found the records do not indicate there is marked lower limb hyperkeratosis or elephantiasis. Our physician reviewer found that there is no documented proximal, including trunk or abdomen lymphedema. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intermittent limb compression device have not been met. Therefore, we decided that the Plan does not have to pre-approve intermittent limb compression device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 29, 2019.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 did not pre-approve the service 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 physician's services provided on August 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and prophylaxis provided on August 21, 2019.
You asked the Plan to pay for the comprehensive oral evaluation and prophylaxis. You say that this provider is recommended for quality and integrity of service. You also say that due to your schedule and time limits, you did not have time to look around for an in-network provider. The Plan denied your request. The Plan says the services were rendered by a non-contracted provider. The Plan also says that these providers are within the time and distance standards set forth by Medicare.
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 out-of-network. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and prophylaxis provided on August 21, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on September 18, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you do not believe you should be charged a second copayment for the same issue within twelve hours. 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 $90 copayment for emergency services. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "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 the emergency room visit provided on September 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 20, 2019 by an out of network provider.
You asked the Plan to pay for therapy services. You say that you were told that authorization was not required for therapy services. The Plan denied your request. The Plan says the referring doctor is also out-of-network. The Plan says that there is no network deficiency for these services and alternate network providers are available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on February 20, 2019 by the out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve monotherapy treatment with Keytruda for the enrollee.
You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says treatment should utilize Pembrolizumab in combination with either carboplatin or cisplatin, and either paclitaxel or paclitaxel protein-bound.
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 Keytruda. Our physician reviewer found that the documentation does not support that monotherapy Keytruda is medically reasonable and necessary for the enrollee without PD-L1 positivity and lack of EGFR and ALK as a single agent in squamous cell carcinoma. The documentation does not support that monotherapy Keytruda is safe and effective for the enrollee. The requested use is listed as not indicated, not supported or not recommended in any of the compendia, as no PD-L1 or other drive mutations tested and it is not in use with other cytotoxic chemotherapy agents. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve monotherapy treatment with Pembrolizumab (Keytruda) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar/sacral orthosis (L0648) provided.
You asked the Plan to pay for the orthosis. You say that the records provided should support the necessity of the services in dispute The Plan denied your request. The Plan says the records did not include an itemized shipping/billing invoice and proof of delivery. There was no evidence of an established relationship between the enrollee and the ordering physician. there were no claims submitted for an evaluation and management service. There is no evidence of prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar/sacral orthosis (L0648) provided.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the spine injection provided on June 18, 2019.
You asked the Plan to waive the copayment for the spine injection. You say that this was just an injection. You say that you are disputing this being billed as surgery. 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 a $335 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital. You have been asked to pay a $335 for the spine injection. The spine injection falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The spine injection is considered a surgical procedure. 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 spine injection provided on June 18, 2019.