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

We decided that the Plan does not have to pay for the central venous catheter insertion rendered on January 4,
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 claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be
exact duplicates of another claim or claim line are denied.
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the
Plan on a separate claim for the same date of service. 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
pay for the central venous catheter insertion rendered on January 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) additional physical therapy (PT) visits.
You asked the Plan to pre-approve eight (8) additional PT visits. You say that additional PT is medically
necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 eight (8) additional PT visits.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent
deterioration of the enrollee's condition. Our physician reviewer found the medical documentation does not
support coverage for additional physical therapy visits. You should be able to do home exercises. The
requested therapy is not generally accepted as specific and effective therapy for your condition. The records do
not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide
treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy
and occupational therapy, by or under the supervision of a therapist. The specialized skill, knowledge and
judgment of a qualified therapist are not required to establish, design and/or deliver a program to maintain your
current condition or to prevent or slow further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of eight (8) additional PT visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve eight (8) additional PT visits
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the primary care office visit you had on March 22, 2021.
You asked the Plan to waive the copayment for the primary care office visit. You say that you do not believe you should have to pay a copayment because this was a follow-up visit. 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 primary care physician services. You have been asked to pay a $10 copayment for the primary care office visit. This copayment applies each time you visit the doctor's office, regardless of the reason for the 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 primary care office visit you had on March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on March 16, 2021 by an out-of-network provider.
You asked the Plan to pay for diffusing capacity (94729), pulmonary function test (94727) and spirometry (94010). You say that you would like the Plan to process the claim based on medical necessity. The Plan denied your request. The Plan says the provider did not request prior authorization as required.
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 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 physician services provided on March 16, 2021 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device (E0601) and a CPAP full mask (A7030).
You asked the Plan to pre-approve a CPAP device and full mask. You say that the items are medically necessary. The Plan denied your request. The Plan says the requested items are covered for in home use only.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that a CPAP device and full mask is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device (E0601) and a CPAP full mask (A7030).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visit you had with a pain
management specialist on March 18, 2021, and the facet joint injection procedure you had at an outpatient
hospital facility on May 4, 2021, to May 5, 2021.
You asked the Plan to waive the copayments for the specialist visit and the injection procedures. You say that
on March 18, 2021, you went to the doctor's office, but they didn't do a procedure that day. You said that all the
doctor's office did was take your blood pressure, asked you some health questions and asked for a urine sample.
You said that you don't believe you should have to pay an office visit copayment for that. You said that because
you didn't feel you received the full dose of medication during the injection procedures, you shouldn't have to
pay that copayment. The Plan denied your request. The Plan says you were charged these copayments
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 $40
copayment for visits with a specialist and a $350 copayment for outpatient hospital services.
You have been asked to pay a $40 copayment for the specialist visit and a $350 copayment for the injection
procedures. The copayment for the office visit applies any time you visit the office, regardless of the extent of
services you receive. In addition, the copayment for the injection procedures you had at an outpatient hospital
facility applies regardless of how much medication you receive. 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
copayments for the office visit you had with a pain management specialist on March 18, 2021, and the facet
joint injection procedure you had at an outpatient hospital facility on May 4, 2021, to May 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on April 27, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you cannot afford this copayment. 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 $250 copayment for ambulance services. You have been asked to pay a $250 copayment for the ambulance services. 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 ambulance services you received on April 27, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve continued services. You say that you are not strong enough to go home. The Plan denied your request. The Plan says you no longer require skilled services.

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 pre-approve continued services. Our physician reviewer found that from a nursing perspective, you received oral medications and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you were at a supervision to independent level with functional mobility. You required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira.

You asked the Plan to pre-approve Humira. You say that this request is medically necessary. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 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 Humira.

Benefits for Humira 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services represented by code 99100 provided on September 29, 2020.
You asked the Plan to pay for code 99100. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Code 99100 has a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided that the Plan does not have to pay for the anesthesia services represented by code 99100 provided on September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), provided on April 7, 2021.

You asked the Plan to pay for a comprehensive oral evaluation. You say that the service should be covered. The Plan denied your request. The Plan says you exceeded the Plan's maximum allowance for this 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. Specifically, you have exceeded the Plan's maximum allowance for this benefit. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), provided on April 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental bone graft surgery (21210).
You asked the Plan to pre-approve bone graft surgery. You say that the enrollee is in major pain, is unable to eat or sleep, and is scheduled for surgery. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this surgery is not covered by the Plan's dental benefits.
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 dental bone graft surgery (21210).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not require skilled nursing or therapy services on an inpatient basis.
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 pre-approve SNF services. Our physician reviewer found that from a nursing perspective, you received oral medications, had stable vital signs, your lungs were clear, and you were treated for pain. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you were at a supervision to setup level with functional mobility. You required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda for the enrollee.

You asked the Plan to pre-approve Keytruda. You say that this is medically necessary for the enrollee. The
Plan denied your request. The Plan says that that the use of Keytruda in this situation is not supported by
compendia utilized by Medicare or in Medicare approved literature.

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 Keytruda. Our reviewer says that
Keytruda is medically reasonable and necessary for the enrollee. Keytruda is not FDA-approved for the
enrollee's diagnosis. The use of Keytruda is supported by one of the major drug compendia or by clinical
research that appears in a Centers for Medicare & Medicaid Services approved medical journal. Our physician
reviewer found that the enrollee's condition meets Medicare criteria for Keytruda.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda have been met. Therefore, we decided that the Plan has to pre-approve
Keytruda 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (K0861,
E2300, E1007, K0108) for the enrollee.
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 medically necessary.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 services. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found there is no
documentation of a need for a power seating system to manage any increased tone or spasticity. There is no use
of intermittent catheterization for bladder management. The enrollee does not have the inability to perform a
functional weight shift.
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 pre-approve a group 3 power wheelchair and accessories (K0861, E2300, E1007, K0108) for the
enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the periodic oral evaluation, prophylaxis and fluoride varnish
application provided on July 14, 2021.

You asked the Plan to pay for the periodic oral evaluation, prophylaxis and fluoride varnish application. You
say that it does not show the benefit maximum and the claim should be reprocessed. The Plan denied your
request. The Plan says that you have no benefits remaining.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not submit documentation showing that $1,000 was paid toward
dental services prior to receiving these services. Therefore, we decided that the Plan has to pay for the periodic
oral evaluation, prophylaxis and fluoride varnish application provided on July 14, 2021.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cataract surgery to be provided by an out-of-network
(OON) provider.
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 available from network providers.
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. Therefore, we decided that the Plan does not have to pre-approve
cataract surgery to be provided by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a posterior walker to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a walker. You say that you need this item. The Plan denied your request. The Plan says you are contractually obligated to obtain services from Plan providers.

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. Therefore, we decided that the Plan does not have to pre-approve a posterior walker 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 pre-approve a tertiary oncology consult.

You asked the Plan to pre-approve a tertiary oncology consult. You say that the recommended provider does not have in-house screening equipment or female providers. The Plan denied your request. The Plan says records submitted do not support the medial necessity for tertiary level of care.

Medicare rules say that plans may specify the networks of providers from whom enrollees may obtain services. 

The Plan policy states tertiary level service is medically necessary when care is needed that the Plan doctors are not able to provide. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a tertiary oncology consult.