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

We decided that the Plan does not have to pre-approve multi-level lumbar fusion.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says spinal fusion should only be considered as a last step in the treatment of chronic back pain, and is not indicated for most persons suffering from back pain.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found criteria for multilevel fusion is not met. There is no documented instability, fracture, or lesion. There is no severe deformity. Multilevel fusion for low back pain is not likely to be successful in relieving low back pain. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve multi-level lumbar fusion.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveelectroconvulsive therapy.You asked the Plan to pre-approvethe requested services. You say that the enrollee needs ECT due to severe agitation and aggression associated with neurocognitive deficits.The Plan denied your request. The Plan says the enrollee has not been given an adequate trial of antipsychotic medication, and the service is not an approved treatment for Alzheimer's Dementia.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that the enrollee had received Geodon for the treatment of agitation. Documentation shows that this enrollee is restless, argumentative, repetitive,has confusion, and yells at staff. There is no indication for the use of this procedure for the treatment of dementia. Based on the information provided, the documentation is not showing medical necessity for the procedure.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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approveelectroconvulsive therapy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit injections.
You asked the Plan to pre-approve the Retacrit. You say that the clinical trial has not yet started and this medication is for maintenance and would not be part of the trial. The Plan denied your request. The Plan says it was confirmed that treatment with the clinical trial was started on January 15, 2020. Treatment of anemia would be necessary to participate in the trial and therefore, the trial must provide this treatment which can be billed to Original Medicare. Routine costs associated with clinical trial treatments are not payable by the Plan.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve the Retacrit which is considered a routine cost of the clinical trial in which you are participating. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Retacrit injections.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on September 16, 2019 by the out of network provider.
You asked the Plan to pay for outpatient lab work. You say that the lab performed all tests that the referring physician ordered. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was obtained.
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 lab work provided on September 16, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour Next EZ test strips for the enrollee.
You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that there is no medical reason documented that you are medically unable to use the preferred meters.
The Plan must follow Medicare rules. Medicare rules say that plans may limit enrollees to preferred providers. The items at issue are Contour Next EZ test strips. Contour Next EZ is not a preferred provider with the Plan for diabetic supplies. ACCU-CHEK and Trividia are the preferred providers. Therefore, we decided that the Plan does not have to pre-approve Contour Next EZ test strips for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says an intensive rehab therapy program would not significantly impact the enrollee's condition.
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's current level of function is self-propelling wheelchair with contact guard assist, sit to stand with minimal assist, supine to sit with minimal assist. She currently has a wound vac in place. The enrollee is currently medically stable. There is no evidence of complex medical issues that require monitoring by an inpatient physician three times per week or acute rehab nursing care. While she may benefit from continuing physical and occupational therapy, there is no evidence of need for 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 decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reimburse the enrollee for the drugs, lodging, and transportation provided on July 13, 2019 and July 14, 2019.
You asked the Plan to reimburse the enrollee for the prescription, lodging, and transportation. You say that the enrollee fell ill while traveling in Canada and could not continue the trip. The Plan denied your request. The Plan says the ambulance and hospital claims are payable but Medicare does not cover drugs purchased in Canada, commercial air travel, or lodging.
The Plan must follow Medicare rules. Medicare rules say that only foreign hospital and ambulance services are covered when outside the U.S. Medicare rules say Medicare drug plans can't cover prescription drugs you buy outside the U.S. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drugs, lodging and transportation have not been met. Therefore, we decided that the Plan does not have to reimburse the enrollee for the drugs, lodging, and transportation provided on July 13, 2019 and July 14, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on July 18, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you had an anxiety attack because you could not get medication. You say that your primary care physician should pay the 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 a $300 copayment per one-way trip by ground or air ambulance. You have been asked to pay a $300 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The records show that you were transported by ambulance to the emergency department. 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 ambulance transport provided on July 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency ambulance (A0429) ground mileage (A0425) provided on June 25, 2019.
You asked the Plan to pay for the ambulance services. You say that you are requesting the plan to re-evaluate the decision to deny this claim as this was an emergency call to 911 and was a matter of life or death. The Plan denied your request. The Plan says the provider billed with codes that indicates noncovered services. The provider needs to sends a corrected claim for reprocessing for payment.
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 A0429 is emergency ambulance service. The plan says that the provider billed the claim with codes that indicates noncovered services. The plan cannot approve payment until the provider submits a new corrected claim. The plan says they have made multiple attempts to obtain a corrected claim from the provider. Once the plan receives a corrected claim from the provider then the claim will be reprocessed fro payment. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for emergency ambulance (A0429) ground mileage (A0425) provided on June 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an admission for skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for SNF care. The Plan says that while awaiting TAVR the enrollee could receive intermittent skilled therapy services at home with HHC under her Part B benefits.
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 the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found from a nursing perspective, the enrollee received oral and inhaled medications. The enrollee had stable vital signs. She used oxygen via nasal cannula. Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT) in the acute hospital. The enrollee was at a minimal assist level with functional mobility including gait to 25 feet x 2 with a rolling walker. The enrollee required varying assist with activities of daily living. Our physician reviewer found that the specialized skill, knowledge and judgment of a skilled professional nurse is not required to safely and effectively provide medically necessary and reasonable treatment. Although there are identifiable skilled therapy service needs, skilled nursing or skilled therapy services (or a combination of these services) was not medically necessary on a "daily basis" in a SNF. As a practical matter you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve an admission for skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee had previously been treated with a program death-directed therapy - Keytruda.
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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found data are evolving in regards to management of resistance to programmed cell death protein 1 (PD-1) axis inhibitors. In general, patients who have progressed on a checkpoint inhibitor may be offered chemotherapy upon progression, either with a platinum-based doublet, if they are chemotherapy naive, or with single-agent chemotherapy, if they are not. However, if progression occurs several months or years after the last dose of PD-1 or programmed cell death ligand 1 (PD-L1) blockade, rechallenge may be attempted, as some responses have been reported. This enrollee has already been rechallenged after progression during a break fro PD-L1 inhibitor and now has progression while on pembrolizumab. Treatment with Opdivo is not reasonable or 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatry services provided on November 15, 2018 by out of network provider.
You asked the Plan to pay for psychiatry services. You say that you were told that the doctor took your insurance. You say that you followed all the rules. The Plan denied your request. The Plan says there are in-network providers available 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. The Services, 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 psychiatry services provided on November 15, 2018 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on September 12, 2019.
You asked the Plan to waive the copayment for the office visit. You say that no other services were performed. You say that the appointment only lasted five to seven minutes. 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 $25 copayment for provider and professional services at an in-network specialist's office. You have been asked to pay a $25 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that only an office visit was billed. 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 office visit provided on September 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe repair of the mandibular partial denture (D5611), and the repair or replacement of broken retentive clasping materials, per tooth, (D5630) for tooth # 27 provided on October 11, 2019.You asked the Plan to pay forthe dental services. You say that you have seen this dentist before. You also say the dentist on the dentist listing.The Plan denied your request. The Plan says the frequency limit has been exceeded. The Plan also says that 1 denture adjustment is covered per calendar year.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 and denture adjustments are covered by the Plan, the frequency limit for denture adjustments has been exceeded. The record shows that the Plan last paid for a dental adjustment on May 28, 2019.Therefore, we decided that the Plan does not have to pay forthe repair of the mandibular partial denture(D5611), and the repair or replacement of broken retentive clasping materials, per tooth, (D5630) for tooth # 27 provided on October 11, 2019
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve neuropsychological testing.
You asked the Plan to pre-approve the neuropsychological testing from your doctor. You say that you need SNF care. The Plan denied your request. The Plan says that there are in-network providers who can supply neuropsychological testing.
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The Plan says that enrollees must use contract providers. Your doctor is a non-contract provider. The records show that the enrollee resides in a metro area and that 30 miles or 45 minutes is the reasonable distance for accessible neurology services. The plan referred the enrollee to another institution for the requested neuropsychological testing. We were able to confirm that these contract providers are not located within reasonable distance and travel time from the enrollee's home. Under Medicare rules, this means that contract providers are not accessible to you. Therefore, we decided that the Plan has to pre-approve the neuropsychological testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on July 2, 2019 by out of network provider..
You asked the Plan to pay for an office visit. You say that you are appealing a denied claim with a non-contracted provider stating that you could not get a referral from your primary care doctor. You say that you work full time and you are only at home on the weekends and some Fridays when you work from home. The Plan denied your request. The Plan says the Physician is not a provider with the health plan. You did not get approval for an office visit. If your primary care provider decides that you require covered services not available from network providers, he or she will recommend to the Plan that you be referred to an out-of-network provider inside or outside our service area.
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 office visit is not included as part of your urgent admission from June 27, 2019 through July 1, 2019 with the out-of-network provider. The urgent admission does not have what is referred to as a global period (meaning services received before or after the urgent admission cannot be included in the cost). 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 an office visit (99214) provided on July 2, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chiropractic office visit (99203) provided September 30, 2019.
You asked the Plan to pay for a chiropractic office visit. You say that you needed this service and should not have to pay for it. The Plan denied your request. The Plan says this service is not covered by Medicare or the Plan.
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. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for a chiropractic office visit (99203) provided September 30, 2019.