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

We decided that the Plan does not have to pre-approve Truxima (rituximab-abbs) 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 use of this product for the requested diagnosis is not supported.
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 based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that Truxima (rituximab-abbs) is medically reasonable, necessary, safe, or effective as defined by the Medicare criteria. 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 Truxima (rituximab-abbs) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for a physical therapy evaluation provided on January 28, 2021.
You asked the Plan to pay for the physical therapy evaluation. The Plan denied your request. The Plan says authorization is required for outpatient physical therapy 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 contract with the Plan also says that authorization is required for outpatient physical therapy services.
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 a physical therapy evaluation provided on January 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone debridement (11044) rendered by the out-of-network (OON) provider on February 2, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the bone debridement (11044) rendered by the out-of-network (OON) provider on February 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower partial denture with flexible base.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not a covered 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a lower partial denture with flexible base.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental surgical services.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan
denied your request. The Plan says the services are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement
of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that
are not covered or paid for by Medicare. While the Plan has a supplemental dental benefit, the file shows that
these services are being requested against the enrollee's medical benefit. Therefore, we decided that the Plan
does not have to pre-approve dental surgical services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutra-pharmaceutical injections and the treatment with the Sanexas device provided on February 11, 2021.

You asked the Plan to pay for the injections and Sanexas treatment. You say that this is a necessary treatment. The Plan denied your request. The Plan says this is not covered by Medicare.

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 pay for the injections and Sanexas treatment. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no support for the use of these injections with electrical stimulation or with vasocompression in the absence of edema. The use of these treatments is not 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 injections and Sanexas treatment have not been met. Therefore, we decided that the Plan does not have to pay for the nutra-pharmaceutical injections and the treatment with the Sanexas device provided on February 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Stabilink procedure for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental for back pain treatment. More research is needed to show the safety and efficacy of the device 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Stabilink procedure for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel.

You asked the Plan to pre-approve Enbrel. You say that you feel this drug should be covered. The Plan denied your request. The Plan says the requested drug is not a covered 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-approve Enbrel.

Benefits for Enbrel 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from April 15, 2021, to May 14, 2021.

You asked the Plan to pay for the services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee required no nursing services which would be considered skilled services by Medicare.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 pay for the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs were custodial and, as a practical matter, could be provided 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from April 15, 2021, to May 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (36415, 80053, 84436, 84443, 84481,
85025, 85610) and the travel allowance, one way in connection with medically necessary laboratory specimen
collection drawn from a home bound or nursing home bound patient (P9604) rendered by the out-of-network
(OON) provider on March 3, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
network provider, without prior authorization.
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 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 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 the laboratory services (36415, 80053, 84436, 84443, 84481, 85025, 85610) and the travel allowance, one way in connection with medically necessary laboratory specimen collection drawn from a home bound or nursing home bound patient (P9604) rendered by the out-of-network (OON) provider on March 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the outpatient surgery and the Part B drugs provided on February 15, 2021.
You asked the Plan to waive the cost share for the outpatient surgery and the Part B drugs. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the claim for date of service, February 15, 2021 has processed correctly.
The Plan says that the contract with the Plan clearly says that outpatient surgery services rendered in an in-network hospital have a $400 copayment. In addition, the Plan contract says Medicare Part B prescription drugs have a 20% coinsurance when performed in-network.
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 $400 copayment for Outpatient hospital services and a 20% coinsurance for Medicare Part B prescription drugs. We looked at the file, the Plan's contract and Medicare rules. You have been asked to pay a $400 copayment for the outpatient surgery and a 20% coinsurance for the Part B drugs, totaling $401.60. The outpatient surgery falls within the Outpatient hospital services benefit category. The Part B drugs falls 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 cost share for the outpatient surgery and the Part B drugs provided on February 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit with a cardiothoracic surgeon to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the office visit with a cardiothoracic surgeon. You say that the enrollee does not want to change providers. The Plan denied your request. The Plan says the provider is out-of-network
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. The records provided for review do not show that the service at issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve an office visit with the cardiothoracic surgeon to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with your primary care provider (PCP) on March 23, 2021.
You asked the Plan to waive the copayment for the PCP visit. You say that this copayment should not apply because you are unhappy with your plan. The Plan denied your request. The Plan says you were charged this copayment 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 visits with your primary care provider. You have been asked to pay a $10 copayment for the PCP visit. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit you had with your primary care provider (PCP) on March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services provided as part of clinical trial (S9991)

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

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 services 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 services provided as part of clinical trial (S9991)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental implant for tooth number 13.
You asked the Plan to pre-approve implant supported crown - porcelain fused to high noble alloys (D6066). You say that you had a crown on this tooth, but it only lasted for 2 weeks. The Plan denied your request. The Plan says dental implants 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a dental implant for tooth number 13.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the tendon sheath incision procedure you had at an ambulatory surgery center on April 1, 2021.
You asked the Plan to waive the copayment for the tendon sheath incision procedure. You say that the facility told you there would be no copayment due to the Coronavirus. The Plan denied your request. The Plan says you were charged this copayment 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 $175 copayment for outpatient surgery or procedures at an ambulatory surgery center. You have been asked to pay a $175 copayment for the tendon sheath incision procedure. The tendon sheath incision procedure falls within the outpatient surgery or procedures at an ambulatory surgery center benefit category. There is no provision in your contract for a waiver of this amount even if it is related to the Coronavirus. 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 tendon sheath incision procedure you had at an ambulatory surgery center on April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99215) and the alcohol and/or substance (other than tobacco) misuse structured assessment (G0396) rendered by an out-of-network (OON) provider on March 12, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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.
You are 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 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 the office visit (99215) and the alcohol and/or substance (other than tobacco) misuse structured assessment (G0396) rendered by an out-of-network (OON) provider on March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the care and services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve care and services. You say that this provider is the most qualified doctor to give you a second opinion regarding your bladder cancer. The Plan denied your request. The Plan says the provider is out-of-network
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. The records provided for review do not show that the services at issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve care and services to be provided by an out-of-network (OON) provider.