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

We decided that the Plan does not have to provide coverage for additional routine transportation trips.

You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your request. The Plan says the benefit only allows up to 24 one-way transportation trips per calendar year. You have used 24 one-way transportation trips for this calendar year.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. The file shows you have used the maximum number of 24 one-way transportation trips. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric treatment.
You asked the Plan to pre-approve inpatient psychiatric treatment. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric treatment. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment
beyond the date in question of October 3, 2021 forward and could have been treated in a lesser restrictive setting as you were not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression. You were being cooperative and compliant while not showing any acute threats to safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wireless capsule endoscopy (91110).

You asked the Plan to pre-approve a wireless capsule endoscopy. You say that a wireless capsule endoscopy is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria outlined in the Plan's Wireless Capsule Endoscopy medical policy.

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 a wireless capsule endoscopy. Our reviewer says that the requested wireless capsule endoscopy is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has multi-systemic disease, and his anemia likely reflects a mixed picture of renal insufficiency, chronic disease, use of multiple "blood thinners", and endoscopic evidence of erosive gastritis. Small bowel follow-thru has shown neither tumors nor inflammatory disease. The medical necessity of wireless capsule endoscopy in this enrollee's setting is not apparent, nor is it likely that the enrollee would tolerate the intervention needed to address small bowel Arteriovenous malformations (AVM's) if found. Further, the study may be relatively contraindicated given his implanted defibrillator/pacemaker.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a wireless capsule endoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a wireless capsule endoscopy (91110).
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 the enrollee is 100% dependent on help and the physicians in charge say he needs rehab 7 days a week. The Plan denied your request. The Plan says the enrollee's needs do not require an interdisciplinary team approach to delivery of rehabilitation care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there are no complex nursing or rehabilitation needs. The patient does not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you have severe incontinence. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on March 23, 2021
.
You asked the Plan to pay for the outpatient services. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for outpatient services provided on March 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement grafts (D4263, D4264) and biologic materials to aid in osseous tissue regeneration (D4265) provided on April 5, 2021, to April 19, 2021.

You asked the Plan to pay for the dental services. You say that you did not know that some providers opt-out of Medicare and you feel you were misled by the Plan's customer service representative. The Plan denied your request. The Plan says they have agreed to make an exception and cover the osseous surgery (D4261) at the out-of-network rate. However, the remaining services are not covered by your dental benefit, regardless of the participation status of the rendering provider.

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 for the bone replacement grafts (D4263, D4264) and biologic materials to aid in osseous tissue regeneration (D4265) provided on April 5, 2021, to April 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular services provided on March 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the cardiovascular services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the cardiovascular services provided on March 19, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Otezla.
You asked the Plan to pre-approve Otezla. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for self-administered drugs have not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Otezla.
Benefits for Otezla 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on February 4, 2021.

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 the claim was processed correctly.

The Plan must follow Medicare rules. The rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. 

Despite multiple attempts by the plan, no medical records with test results were received. 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 laboratory services provided to the enrollee on February 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided January 26, 2021 to February 24, 2021.
You asked the Plan to pay for the hospital services. You say that you had just received a bill from when you were hospitalized in March 2021. You had called the Plan and was told you just had to pay $773.11 as required out of pocket 2021 individual in network. The Plan denied your request. The Plan says this claim was processed and the correct copayment was applied per the Evidence of Coverage.
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 $250 copayment per day for days 1-6 and $0 copayment per day for days 7-90. You have been asked to pay $1,500 ($250 x 6 days = $1,500) for the hospital services. Your maximum out of pocket amount is $3,450. The records show as of March 26, 2021 you had met only $3,430.74 of your maximum out of pocket. The hospital services fall within the Inpatient hospital 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 pay for the inpatient hospital care provided January 26, 2021 to February 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on May 19,
2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.

The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography
angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with
column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment.
Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on
May 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
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 medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found you have a diagnosis of lumbar spinal stenosis. The requested Superion spacer is considered experimental in nature, as more research is needed to show safety and efficacy. The services are therefore 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for imaging of the retina (92134) and an eye injection (67028) provided on April 15, 2021.

You asked the Plan to waive the deductible for imaging of the retina and an eye injection. You say that you are an established patient with the provider and have never received a bill for services. The Plan denied your request. The Plan says the claim was correctly processed with the applicable deductible.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $198 deductible which applies to covered medical services.

The service at issue is subject to the Plan deductible of $198. The record shows that at the time this claim was processed, $0 of the $198 deductible had been met. The allowed amount of the claim is $82.12, resulting in a deductible obligation of $82.12. Please note, our decision is only regarding Medicare benefits. The Plan indicated that you are not being billed by the provider due to Medicaid coverage and you can contact the Plan for more information. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $198 deductible which applies to covered medical services. This cost sharing is a contractual obligation that had not been met at the time imaging of the retina and an eye injection was received on April 15, 2021. Therefore, we decided that the Plan does not have to waive the deductible for imaging of the retina (92134) and an eye injection (67028) provided on April 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Ilumya (J3245).

You asked the Plan to pre-approve Ilumya. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy for the requested 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 to pre-approve Ilumya. Our reviewer says that the requested drug is not medically necessary in this case. Our physician reviewer found that the Plan requires a trial of drugs Remicade or Inflectra and Stelara before they will approve the requested drug, Ilumya. Based on the medical records provided, the enrollee has not tried and failed the required drugs. There is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Ilumya (J3245).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided from September 18, 2020, to October 1, 2020.
You asked the Plan to pay for home health care. You say that you are appealing with supporting records and should be paid in full. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is not enrolled in Medicare and is not eligible for payment.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered items or services, a provider must be enrolled in the Medicare program. We looked at the file and Medicare rules. This provider is not enrolled in Medicare and is not eligible for payment. Based on this information, we decided that Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided from September 18, 2020, to October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy.
You asked the Plan to pre-approve massage therapy. You say that you would like the Plan to reconsider their
denial. The Plan denied your request. The Plan says massage therapy is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore,
we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm.

You asked the Plan to pre-approve Aduhelm. The Plan denied your request. The Plan says this drug 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 Aduhelm. Our reviewer says that Aduhelm is not medically reasonable and necessary in this case. Our physician reviewer found that Aduhelm is indicated for the treatment of Alzheimer's disease in patients with mild cognitive impairment or the mild dementia stage of the disease. The documentation is insufficient to confirm a diagnosis of Alzheimer's disease in this enrollee. There is insufficient evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains. It has not been shown that Aduhelm is at least as beneficial as existing and appropriate and available medically appropriate alternatives for this enrollee's condition. The documentation is insufficient to support that the drug is expected to be safe and effective for the enrollee in this case. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services provided by an out-of-network provider from December 7, 2020, through December 8, 2020.

You asked the Plan to pay for the surgery services. You say that the services provided were medically necessary and equal with treatment standards for the patient. You say that the claim should be reviewed for medical necessity and overturned. The Plan denied your request. The Plan says the services required authorization and authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the surgery services provided by an out-of-network provider from December 7, 2020, through December 8, 2020.