Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oncology services to be provided by an out of network provider.

You asked the Plan to pre-approve an evaluation with an out of network medical oncologist.. You say that the enrollee has a rare medical condition and need to be seen by this provider. The Plan denied your request. The Plan says they have specialists in network who can provide the services the enrollee needs.

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 oncology services to be provided by an out of network provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Supartz Fx medication (J7321).

You asked the Plan to pre-approve this medication. You say that this medication is medically necessary.The Plan denied your request. The Plan says you have not met the step therapy criteria for coverage of this medication.

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 this medication. Our reviewer says you have not met the step therapy criteria for coverage of this medication. Our physician reviewer found that the Plan requires a trial of Orthovisc and Monovisc medications before they will approve the requested drug. In this case, you have not tried and failed the required drugs. Additionally, there is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or would likely have adverse effects for you.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this medication have not been met.Therefore, we decided that the Plan does not have to pre-approve the Supartz Fx medication (J7321).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray provided on September 14, 2020.

You asked the Plan to pay for the x-ray. You say that you only have access to the results and the enrollee's hospice eligibility. You also say that the enrollee's hospice eligibility ended. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on September 11, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the chest x-ray provided on September 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies rendered on February 28, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid proof of delivery.

The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. 

We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 pay for the supplies rendered on February 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by the requested provider.

You asked the Plan to pre-approve the office visits. The Plan denied your request. The Plan says this physician is not licensed by the state of Massachusetts and is not in-network with the Plan.

The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. 

The services at issue in this appeal are naturopathic services.Therefore, we decided that the Plan does not have to pre-approve office visits to be provided by the requested provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that acute rehabilitation is the best chance for the
member to return to her prior level of function. The Plan denied your request. The Plan says that the enrollee
can safely receive the services needed, in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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. The
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for leg pain and a fall.
The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary
care can be provided in a different level of care. There is not a reasonable expectation that this patient will be
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on December 8, 2020.

You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 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 outpatient hospital services provided on December 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-ray (D0274) received from an out-of-network (OON) provider.

You asked the Plan to pay for the bitewing x-ray. You say that you verified that the provider was in-network prior to obtaining services, therefore you should not be responsible for payment. The Plan denied your request. The Plan says the plan pays according to a maximum allowable fee schedule and you pay all fees in excess of this amount.

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 payment is in excess of that which is covered under this benefit. The Plan contract states you are responsible for any amount above the maximum allowable fee, and you pay all fees in excess of this amount. The Plan allowed $0 for this service; therefore you are responsible for the full charge. Therefore, we decided that the Plan does not have to pay for the bitewing x-ray (D0274) received from an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral exam received from an out-of-network (OON) provider.

You asked the Plan to pay for the comprehensive oral exam. You say that this provider participates in the Plan's network. The Plan denied your request. The Plan says items and services received from an out-of-network provider are 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 Plan does not cover items and services received out-of-network. The Plan has confirmed that the provider in this case was not in-network on the date of service. Therefore, we decided that the Plan does not have to pay for the comprehensive oral exam received from an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tertiary-level cardiology referral.
You asked the Plan to pre-approve the referral. You say that this is necessary for a diagnosis of brachycardia. The Plan denied your request. The Plan says the medical records do not support medical necessity for care at the tertiary level.
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 referral. Our reviewer says that the requested referral is not considered medically reasonable and necessary in this case. Our physician reviewer found you have standard cardiology issues, which do not require management at the tertiary level, including pacemaker interrogation and follow-up, hypertension and congestive failure management. As these conditions are readily and regularly managed by community based, in-network provider cardiology services, it is not medically necessary to have specialized tertiary center follow-up. There is also a medical note that he was seen already by an in network cardiology provider and his pacemaker and other follow-ups have been appropriately initiated. 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 referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a tertiary-level cardiology referral.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you really need inpatient rehabilitation. The Plan denied your request. The Plan says the medical records do not support the need for an intensive rehabilitation therapy program.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 there are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an eye examination with a tertiary level of care
provider.
You asked the Plan to pre-approve eye exam. You say that the enrollee's vision is deteriorating and there has
been no help from doctors. The Plan denied your request. The Plan says the denial of authorization for this
service is correct, because the enrollee does not need to be treated at the tertiary level of care and this request is
for a low vision evaluation which is not covered.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan
providers available to meet the enrollee's needs. The enrollee's contract with the Plan says that, with few
exceptions, enrollees 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 eye exam. Our reviewer says that the
enrollee does not meet the criteria for treatment at the tertiary level of care. Our physician reviewer found the
Plan's denial is medically justified on the basis that it is offering adequate care to meet the enrollee's medical
needs through referral to a non-tertiary level of care provider. There is nothing unique about the enrollee's
condition that would make it medically necessary for her to see the requested tertiary level of care provider.
The Plan has shown that they have non-tertiary providers who meet the standards of care required for treatment
of the enrollee's condition. An eye examination by a tertiary level of care provider 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 eye exam have not been met. Therefore, we decided that the Plan does not have
to pre-approve an eye examination with a tertiary level of care provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive evaluation (D0150), panoramic x-ray (D0330), nitrous oxide analgesia (D9230), extraction (D7140) and the partial dentures (D5213, D5214) provided on October 19, 2020.

You asked the Plan to pay for the dental services. You say that your husband saw this same dentist. His appointment was set up by a Plan representative, and he was reimbursed for the services provided. You do not understand why your services are now being denied when his were covered. The Plan denied your request. The Plan says they made a one-time exception for your husband due to a misunderstanding, but at the time of his claim several months earlier you were notified that this provider has opted-out of Medicare and future services from this provider would not be covered. The Plan will only cover services provided by a licensed dental provider who is eligible under 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, services and items received from a provider who does not participate in Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive evaluation (D0150), panoramic x-ray (D0330), nitrous oxide analgesia (D9230), extraction (D7140) and the partial dentures (D5213, D5214) provided on October 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are 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 in the Medicare rules section.

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 were admitted for falls and a humeral fracture. Your medical problems are stable. The documentation does not support that you require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that you require an intensive rehabilitation therapy program. Your care needs can be met at a lower level of 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapy dog.
You asked the Plan to pre-approve the dog. You say that this is needed to help with anxiety and depression. The Plan denied your request. The Plan says this is not medically necessary for the purpose of diagnosis or treating illness or injury, or to improve the functioning of a malformed body member
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. A therapy dog is not considered a medical request. It cannot be considered medically necessary. Based on this information, we decided that Medicare rules for coverage of the dog have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapy dog.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ziextenzo for the enrollee.

You asked the Plan to pre-approve the drug. You say that the enrollee is in the middle of therapy, and not having the medication could cause you to be hospitalized.The Plan denied your request. The Plan says the claims for routine costs associated with the clinical trial are not covered.

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 drug as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials.Therefore, we decided that the Plan does not have to pre-approve Ziextenzo for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement continuous positive airway pressure (CPAP) device and humidifier.
You asked the Plan to pre-approve a CPAP and humidifier. You say that your CPAP is not working, and you need to have it replaced. The Plan denied your request. The Plan says medical necessity is not supported by medical records from your physician.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. We looked at the file, and Medicare rules. There are no medical records to support criteria for the CPAP and humidifier. Based on this information, we decided that Medicare rules for coverage of a CPAP and humidifier have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement continuous positive airway pressure (CPAP) device and humidifier.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required provided on October 14, 2020.

You asked the Plan to pay for the core buildup. You say that you would like this service to be covered. The Plan denied your request. The Plan says your annual maximum benefit is exhausted.

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 Plan offers a $1,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit while processing this claim for the October 14, 2020 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required provided on October 14, 2020.