Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient appears to be worsening and is unstable and requires additional short-term acute care services to help stabilize the patient which can be safely completed at the current facility. The patient does not require services at the LTACH that are not already available and covered at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may be considered when the patient is more stable and treatment has completed. 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 LTACH services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency ambulance services (A0427) provided on October 7, 2020.You asked the Plan to waive the copayment forthe emergency ambulance services. You say that you were under the impression that emergency transportation would be fully covered.The Plan denied your request. The Plan says the copayment has applied correctly in this case.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 $325 copayment for ambulance services.You have been asked to pay a $325 copayment for the emergency ambulance services. The services provided fall within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe emergency ambulance services (A0427) provided on October 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Farxiga 10 mg tablet.
You asked the Plan to pre-approve Farxiga. You say that this service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this medication does not fall under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Farxiga 10 mg tablet.
Benefits for Farxiga may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee
is not an imminent risk of harm to herself or others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
Continued services beyond January 20, 2021, were requested. 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 continued services. Our physician reviewer found that active treatment was not taking
place. The services were not reasonably expected to improve the enrollee's condition, or for the purpose of
diagnosis. The enrollee was not shown to be a danger to herself or others. She was not showing any auditory or
visual hallucinations. She was cooperative/compliant with treatment while not showing any threats the safety.
Based upon review the records provided, the enrollee does not meet the criteria for continued acute inpatient
mental health treatment beyond January 20, 2021.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does
not have to pre-approve continued inpatient mental health services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Foundation One CDx genomic profiling test provided to the enrollee.

You asked the Plan to pay for the test. You say that you are the developer and sole provider of the Foundation One CDx genomic profiling test.The Plan denied your request. The Plan says the provider is not Medicare-certified.

The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are enrolled in the Medicare program.

You are not eligible to bill Medicare. iCare did not pre-approve the test. We found no exception that would require iCare to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the Foundation One CDx genomic profiling test provided to the enrollee
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveMycophenolate Mofetil 500mg tablet.You asked the Plan to pre-approvethe drug. You say that this is medically necessary.The Plan denied your request. The Plan says coverage for this drug can be provided through the Medicare Part D benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveMycophenolate Mofetil 500mg tablet.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered on February 14, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not filed timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for these services was not filed until October 21, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe services rendered on February 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetransfer bench, heavy-duty, for tub or toilet (CPT Code E0248).You asked the Plan to pre-approvethe bench. You say that the bench is necessary.The Plan denied yourrequest. The Plan says bath tub seats are denied because they are classified as a "comfort or convenience item; hygienic equipment; not primary medical in nature."The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore,we decided that the Plan does not have to pre-approvetransfer bench, heavy-duty, for tub or toilet (CPT Code E0248).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRFadmission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is 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 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 requestedIRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found 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's medical status does not currently require intensive physician and nursing oversight only in an IRF. The patient may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the patient's functional status requires  or can tolerate 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 IRF admission and services.
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 IRF care is medically necessary for the enrollee. The
Plan denied your request. The Plan says rules for IRF care have not been 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 the complexity of the patient's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, 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 documents a need for
physical and occupational therapy, it does not document a need for an intensive rehabilitation program. Finally,
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pegfilgrastim 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 records do not show the criteria has been met.
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 the enrollee has had
prior chemotherapy and is older than 65 years of age. Her risk of neutropenic fever is exaggerated by these risk
factors but the risk of neutropenic fever with the use of Navelbine is only 8% (low risk). Therefore, she is
unlikely to require the use of growth factors. The service 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 Pegfilgrastim for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for immunotherapy service provided on June
29, 2020.
You asked the Plan to waive the copayment for specialist visit. You say that the cost-share for this service was
not in the Evidence of Coverage or Annual Notice of Change for 2020. The Plan denied your request. The Plan
says the copayment amount you are being charged is correct.
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 $35
copayment for specialist visit.
You have been asked to pay the allowed amount of $10.36, which is less than the $35 copayment for specialist
visit. Specialist 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 for immunotherapy service provided on June 29,
2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xolair.
You asked the Plan to pre-approve Xolair. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says this drug is not being requested for a medically-accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Xolair. Our reviewer says that based on the medical records provided there is no documentation that Xolair is indicated for this enrollee's asthma. Our physician reviewer found there is no evidence of specific allergic sensitivity confirmed by a positive skin test or in-vitro reactivity to a perennial aeroallergen. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Xolair have not been met. Therefore, we decided that the Plan does not have to pre-approve Xolair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 3.
You asked the Plan to pre-approve the dental service. You say that the core build up is necessary. The Plan
denied your request. The Plan says core build up is not listed as a covered service.
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. The Customer Handbook clearly states that if a dental item or service
is not listed in the benefit chart or listed with NC, then it is not covered. Therefore, we decided that the Plan
does not have to pre-approve core build up (D2950) for tooth # 3.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe laboratory services rendered on September 22, 2020.You asked the Plan to waive the copayment forthese services. You say that the services should be part of a yearly exam with no copayment.The Plan denied your request. The Plan says the copayment 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 $10 copayment for Medicare-covered laboratory tests. Review of the file shows that you received laboratory services on September 22, 2020. These services fall outside of the scope of an annual exam. You have been asked to pay a $10 copayment for these services. These services fall within theMedicare-covered laboratory tests 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 laboratory services rendered on September 22, 2020
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on May 20, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment. You say you went to the emergency room because the doctor instructed you to so. 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 $50 copayment for emergency care. You have been asked to pay a $50 copayment for the emergency room visit. The 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 the emergency room visit provided on May 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for the biopsy provided.

You asked the Plan to waive the co payment for the biopsy. You say that you do not have to pay this bill because the doctor did not get the tissue and got the nerve. 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 co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 co payment for outpatient surgery services. You have been asked to pay a $300 co payment for the biopsy. The biopsy falls within "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The medical record shows the ultrasound-guided biopsy was successfully completed.

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 co payment for the biopsy provided.
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 disagree with the denial. The Plan denied your
request. The Plan says the 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 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 medically necessary. Our physician reviewer found the enrollee was admitted to the
hospital for a gastrointestinal (GI) bleed and anemia. Her medical conditions are stable and there are no
medical needs requiring an inpatient admission. She has no complex nursing or rehabilitation needs. She does
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. While the medical record documents a need for physical and
occupational therapy, it does not document a need for an intensive rehabilitation program.
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 pay forcardiology services (93000, 99213, G8427) provided on June 1, 2020.You asked the Plan to pay forthe cardiology services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not emergent. There were network providers available.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forcardiology services (93000, 99213, G8427) provided on June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 1, 2019.You asked the Plan to pay forthe services provided. You saythat you depend on the facility for timely notification of the enrollee's insurance coverage.The Plan denied your request. The Plan says the claim was received past the allowed timeframe.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for the services provided was not filed until September 15, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe medical services provided on June 1, 2019