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

We decided that the Plan does not have to waive the coinsurance forthe emergency room (ER) services rendered on December 18, 2019.You asked the Plan to waive the coinsurance forthese services. You say that you had met your maximum out of pocket amount.The Plan denied your request. The Plan says the coinsurance was 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 20% coinsurance but not more than $50 for each emergency room visit. Review of the file shows that you received ER services on December 18, 2019. Per the contract with the Plan, there is a 20% coinsurance but not more than $50 for each emergency room visit. At the time the claim was processed, you had only met $702.10 of the $910 maximum out of pocket amount. You have been asked to pay a 20% coinsurance for these services, for a total of $33.73. These services fall within the emergency room visit 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 coinsurance forthe emergency room (ER) services rendered on December 18, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on October 18, 2019.You asked the Planto waive the copayment for an emergency room visit. You say that you were just following instructions and you should not be charged another copayment for this. The Plan denied your request. The Plan says the correct copayment has been applied.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 $110 copayment for emergency care. You have been asked to pay a $110 copayment for an emergency room visit. Since an emergency room visit occurred, the correct copayment has been applied. An emergency room visit falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on January 23, 2020.
You asked the Plan to waive the copayment for a specialist office visit. You say that you did not fill the prescription that was written for you. You say that you do not feel like this visit warrants a $50 copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $50 copayment for physician/practitioner services/specialist visit. You have been asked to pay a $50 copayment for a specialist office visit. A specialist office visit falls within the physician/practitioner services/specialist visit 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 a specialist office visit provided by a participating provider on January 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 71045) provided to the enrollee on October 11, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Medicare does not pay separately for this service.
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, we have confirmed that code 71045 has a bundled relationship with code 71046 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (CPT 71045) provided to the enrollee on October 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on January 6, 2020. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified. The Plan must follow Medicare rules. Medicare rules say that 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. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on January 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on December 19, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is nota network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on December 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe removal of impacted tooth (D7240) and therapeutic parenteral drug (D9610) provided on February 11, 2020.You asked the Plan to pay forthe removal of impacted tooth and therapeutic parenteral drug. You say that you believed the surgery was necessary to be completed before any other work was to be done. You also say that you are on a fixed income.The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.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 forthe removal of impacted tooth (D7240) and therapeutic parenteral drug (D9610) provided on February 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the health club membership.
You asked the Plan to pay for the health club membership. You say that your doctor recommended you for a fitness/weight loss program. The program is focused on weight loss requirements. You do not understand why there is a problem in processing the reimbursement. The Plan denied your request. The Plan says the program is not considered a weight loss program, therefore it does not qualify for the weight loss reimbursement benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only The plan will reimburse members up to an annual maximum of $150 towards program fees for weight loss programs. The plan will cover program fees for weight loss programs such as Weight Watchers, Jenny Craig, or a hospital-based weight loss program. The Plan's rules for coverage of gym benefits have not been met because the requested reimbursement was for a fitness/ wellness program which focuses on yoga, Pilates and somatics. This type of program is not considered a weight loss program, therefore it does not qualify for the weight loss reimbursement benefit. Therefore, we decided that the Plan does not have to pay for the health club membership.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable control system and seat elevation feature
for the power wheelchair.
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says alternative
drive controls may be required to allow independent power functions due to decreased strength and motor
control.
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered
under certain medical indications.
The records show that a seat elevation feature was requested. We looked at the file and the rules. A power seat
elevation feature is non-covered because it is not primarily medical in nature.
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 an expandable control system. Our
physician reviewer found that the expandable controller in not medically necessary as you do not require a
proportional input device other than a joystick, a non-proportional input device, a need to control 3 or more
actuators through the drive control. You do not need a separate display, other electronic device, an attendant
control. The approved power options can be controlled by their individual switches, and your strength and
functional level are sufficient to control these switches.
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 items have not been met. Therefore, we decided that the Plan does
not have to pre-approve an expandable control system and seat elevation feature for the power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveproton beam radiation therapy.You asked the Plan to pre-approvethe requested services. You say that the proposed treatment plan is reasonable and appropriate to treat the enrollee's condition.The Plan denied your request. The Plan says there is no compelling data to show that proton therapy is more beneficial than IMRT or IGRT for prostate cancer.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 there is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms of definitive radiation therapy. To date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients.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-approveproton beam radiation therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea cold therapy pump.You asked the Planto pre-approvethe cold therapy pump. You say that this item is necessary for use after your hip replacement surgery.The Plandenied your request. The Plansaysthis item is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that cold therapy pumps are not considered medically reasonable and necessary.Although this may be appropriate for you, neither Medicare nor your plan provide coverage for this item.Therefore, we decided that the Plandoes not haveto pre-approvea cold therapy pump.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says your medical condition is not medically complex, and does not need an intensive team approach to rehab.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 you are at minimal assist to moderate assist for ambulation with a walker. You are at standby to maximum assist for activities of daily living. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple therapies, such as physical and occupational therapy, but the documentation does not support that your functional level requires an 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to pre-approvenuclear stress test. We decided that the Plan does not have to pre-approveTransthoracic Echocardiogram. You asked the Plan to pre-approvenuclear stress test. You say that you would like the plan to reconsider their denial.The Plan says that the requested services are not medically necessary. We decided that the Planhas to pre-approvea nuclear stress test. The Plan follows Medicare rules. Medicare rules say that a Nuclear Stress Tests are covered when it is for re-evaluation of disease in patients who are asymptomatic or have stable symptoms, with known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, who have not had a revascularization procedure within the past two years or greater than 2 years since last imaging study.We asked our physician reviewer to carefullyreview the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve nuclear stress test. Our reviewer saysthat the documentation doessupport that the requested repeat nuclear stress test is medically reasonable and necessary. Our physician reviewer found the enrollee meets criteria for the requested nuclear stress test because it is for the re-evaluation of disease in enrollees who are asymptomatic or have stable symptoms, with known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, who have not had a revascularization procedure within the past two years or greater than 2 years since last imaging study.We looked at this physician's review, the file, and Medicarerules. Based on this information, we decided that Medicare rules for coverage of nuclear stress test have been met.Therefore, we decided that the Plan has to pre-approvea nuclear stress test. We also decided that the Plandoes not have to pre-approveTransthoracic Echocardiogram.The Plan follows Medicare rules. Medicare rules say that a Transthoracic Echocardiogram (TTE) are only covered for certain indications.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 Transthoracic Echocardiogram. Our reviewer says that the documentation does not support that the requested TTE is medically reasonable or necessary. Our physician reviewer found the enrollee previously received an echocardiogram. The enrollee has known coronary disease but no valve disease. Therefore, the enrollee does not meet criteria for the requested repeat echocardiogram.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Transthoracic Echocardiogram have not been met.Therefore, we decided that the Plan does not have to pre-approveTransthoracic Echocardiogram.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveXgeva (denosumab).You asked the Plan to pre-approveXgeva. The Plan denied your request. The Plan says the step therapy requirements have not been met.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 topre-approve Xgeva. Our reviewer says that the enrollee has not met the step therapy requirements for coverage of the requested drug. Our physician reviewer found that the documentation does not show that the enrollee has tried and failed pamidronate or zoledronic acid. Additionally, the documentation shows no evidence of renal insufficiency.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Xgeva have not been met.Therefore, we decided that the Plan does not have to pre-approveXgeva (denosumab)
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 IRF care is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria for IRF care are not met.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 thecomplexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitationcare. Your medical status does not currently require intensive physician and nursing oversight only in an IRF. The documentation does not support that you can tolerate or that your functional level requires an intensive rehabilitation therapy program provided in an IRF.Medicare coverage criteria are not met. 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveKeytruda and Pemetrexed.You asked the Plan to pre-approvethe requested drugs. The Plan denied your request. The Plan says the use of the drug regimen requires no progression of disease, and further treatment requires stability for continuation.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested drugs. Our physician reviewer found that the review relates to a request to continue maintenance Pemetrexed with Pembrolizumab (Keytruda) to treat progressive brain metastasis and stable or decreasing lung cancer. The combination is not FDA approved. The combination is not supported in any of the CMS approved compendia in the setting of progression of the cancer. The combination is supported by the NCCN compendium if there is stable disease following initial systemic therapy. The enrollee has progression of the cancer in her brain. There is no recommendation to treat brain only progression differently than any othertype of progression. The use is not specifically listed as not indicated, not supported, or not recommended in any of the compendia.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 drugs have not been met. Therefore, we decided that the Plan does not have to pre-approveKeytruda and Pemetrexed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean Optune device andrelated supplies.You asked the Plan to pre-approvethe requested items. The Plan denied your request. The Plan says tumor treatment field therapy is not necessary for recurrent glioblastoma.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The file shows that the Optune device was requested for recurrent anaplastic oligodendroglioma. We looked at the file, and Medicare rules.Tumor treatment field therapy isdenied as not reasonable and necessary for the treatment of recurrent GBM.Based on this information, we decided that Medicare rules for coverage of the requested items have not been met.Therefore, we decided that the Plan does not have to pre-approvean Optune device and related supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea TENS device.You asked the Plan to pre-approvethe requested device. You say that you have already gone to a neurologist, and tried physical therapy.The Plan denied your request. The Plan says you are not in a Medicare-approved clinical trial for this device.The Plan must follow Medicare rules. Medicare rules say that a TENS device is only covered under certain medical indications. We looked at the file and Medicare rules. The records do not show that you are enrolled in an approved clinical study. Based on this information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approvea transcutaneous electrical nerve stimulation (TENS) device.