Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more forthe crown (D2740), core build up (D2950), and the extraction (D7210) provided on May 2, 2019 by the out of network dentist.You asked the Plan to pay more forthe dental services. You say that you needed to have these services due to infections. You also say that your disability income will not be able to cover these high amounts.The Plandenied your request. The Plan says the provider in this case is not a network provider. The Plan says that the claim was already processed according to the in network benefit.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 the services you received are listed as covered, you pay a coinsurance amount for comprehensive dental services. The record shows that this claim was processed at the in network cost share rate. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage.Therefore, we decided that the Plan does not have to pay more for the crown (D2740), core build up (D2950), and the extraction (D7210) provided on May 2, 2019 by the out of network dentist.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).You asked the Plan to pre-approve the SNF admission. You say that this is medically necessary due to the new findings.The Plan denied your request. The Plan says there is no evidence of a need for daily skilled nursing care and the patient is not active in intermittent therapy so daily therapy would not be useful.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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is an 85 year old female with recently diagnosed liver cirrhosis and currently in the facility for LTC. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. Regarding rehabilitation services, the beneficiary received PT and OT in the SNF. The beneficiary was at a maximal assist of 2 level with bed mobility and transfers and could ambulate 10 feet with minimal assist and a rolling walker. The beneficiary required varying assist with ADLs.There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. This beneficiary 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 admission have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on November 20, 2019You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 thePlan. The Plan did not pre-approve the servicesat 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 a domiciliary, rest home visit provided on November 20, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says your needs are mainly custodial.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 SNF services. Our physician reviewer found that from a nursing perspective, you had stable vital signs, and your lungs were clear. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at a contact guard assist level with functional mobility. You require varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forphysical therapy provided from September 20, 2019 to September 26, 2019.You asked the Plan to pay forphysical therapy. You say that you were told that you were being referred for treatment for your ear pain.The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by Medicare for a diagnosis of temporomandibular joint (TMJ) disorder.The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only when the condition or symptom is medical in nature. The treatment must also be medically reasonable and necessary. We asked ourphysician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for physical therapy. Our reviewer says that you do not meet the Medicare criteria for this temporomandibular joint (TMJ) disorder treatment. Our physician reviewer found the documentation supports the diagnosis of temporomandibular joint (TMJ) disorder. According to the documentation, the underlying cause of your ear pain was this TMJ disorder. The physical therapy was targeted toward the underlying diagnosis, and not for the symptom of ear pain. Physical therapy can be reasonable for the treatment of TMJ disorder, but this is not covered under Medicare guidelines.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met.Therefore, we decided that the Plan does not have to pay forphysical therapy provided from September 20, 2019 to September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forlaceration repair (41250) provided on April 12, 2019.You asked the Plan to pay for the laceration repair. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitteddoes not support that this service was rendered on the billed date of 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, the CPT Code Manual definition of code 41250 is repair of laceration 2.5 cm or less; floor of mouth and/or anterior two-thirds of tongue.We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the laceration repair. Our reviewer says that CPT code 41250 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation of a repair of laceration 2.5 cm or less; floor of mouth and/or anterior two-thirds of tongue performed on April 12, 2019, therefore this service cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laceration repair have not been met. Therefore, we decided that the Plan does not have to pay for laceration repair (41250) provided on April 12, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint radiofrequency neurolysis.You asked the Plan to pre-approvefacet joint radiofrequency neurolysis. You say that you are appealing with records.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the doctor must send notes saying how much the enrollee's pain makes activity harder and that the pain was reduced by at least 80% from the previous 2 injections.The Plan follows Medicare rules. Medicare rules say that radiofrequency neurotomy may only be considered when dual medial branch blocks (MBBs) provide greater than 80% relief of the primary pain.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 facet joint radiofrequency neurolysis. Our reviewer says that the enrollee does not meet the Medicare criteria for radiofrequency neurolysis. Our physician reviewer found the enrollee had one set of diagnostic medial branch blocks which provided 80% pain relief, but he has not had a second confirmatory block. Theenrollee needs a second diagnostic medial branch block before performing the requested radiofrequency neurotomy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage offacet joint radiofrequency neurolysis have not been met. Therefore, we decided that the Plan does not have to pre-approvefacet joint radiofrequency neurolysis.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the injections provided on January 29, 2020.You asked the Plan to waive the coinsurance for the injections. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received Medicare Part B injections on the date of service at issue in this appeal. The Plan states the correct coinsurance has applied per your contract with the Plan.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 for Medicare Part B prescription drugs. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received injections on January29, 2020. You have been asked to pay a 20% coinsurance for the injections, totaling $231.36. The injections fall 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 coinsurance for the injections provided on January 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Belimumab.You asked the Plan to pre-approveBelimumab. You say that your condition flares up when not on this medication.The Plan denied your request. The Plan says there is no documentation of active systemic lupus.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 Belimumab. Our physician reviewer found that there is no record of the anti-nuclear antibody titer, or the anti-double stranded DNA level documented in the medicalnotes to confirm the diagnosis of active systemic lupus erythematosus. The documentation does not support that Belimumab is medically reasonable and 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 Belimumab have not been met. Therefore, we decided that the Plan does not have to pre-approveBelimumab.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vectibix.You asked the Plan to pre-approve Vectibix. You say that the requested Vectibix is medically necessary.The Plan denied your request. The Plan says the requested Vectibix is not medically necessary.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 Vectibix. Our reviewer says that the requested Vectibix is not medically necessary. Our physician reviewer found the enrollee is diagnosed with squamous cell carcinoma of the neck. Vectibix is not FDA-approved for the enrollee's diagnosis in this case. The use of Vectibix for the enrollee's condition is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vectibix have not been met.Therefore, we decided that the Plan does not have to pre-approveVectibix.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Soliris for the enrollee.
You asked the Plan to pre-approve Soliris. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that that the is not medically necessary.
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 Soliris. Our reviewer says that Soliris is medically reasonable and necessary for the enrollee in this case. In this case the patient has AChR positive myasthenia gravis. Laboratory results were also provided to support/confirm the diagnosis. The FDA has approved Soliris for use in "adults for the treatment of generalized myasthenia gravis in patients who are anti-acetylcholine receptor antibody positive." The drug's (FDA) approved labeling does not otherwise require that there be any other medication trials noted or a baseline MG-ADL score. The records provided otherwise did not show that the patient has any (medical) contraindications to the use of the requested drug. Our physician reviewer found that the enrollee's condition meets criteria for coverage of Soliris. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Soliris have been met. Therefore, we decided that the Plan has to pre-approve Soliris for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says physician supervision by a rehab physician is not required face to face three times per week.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you were medically stable with no evidence of a need for supervision by a PMR physician. There is no need for acute rehab nursing care. You may benefit from further PT and OT, but you do not require an intensive therapy program. IRF admission is not medically necessary based on your current functional status, and medical stability. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
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 reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) following emergency surgery for an aortic dissection. The enrollee is not currently intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist office visit provided by out of network provider, on September 30, 2019.You asked the Plan to waive the copayment forthe specialist office visit. You say that you have been seeing this doctor monthly and have never been asked to pay a copayment.The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for each covered visit or consultation in an outpatient location with a specialist. You have been asked to pay a $15 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 forthe specialist office visit provided on September 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not have to pre-approve admission to an inpatient rehabilitation facility (IRF). You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says the services can be provided at an alternate level of care, such as a subacute rehabilitation environment, or a home environment with home health services.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you are medically stable with no evidence of need for supervision by a PMR physician. There is no need for acute rehab nursing care. It is not clear what your functional status is to determine that you need an IRF admission. However, the admission is not medically necessary based on your current medical stability.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).