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

 We decided that the Plan does not have to pay for the surgical removal of an implant body (D6100) provided on August 17, 2021 by a Medicare opt out provider.  You asked the Plan to pay for the surgical removal of an implant body. You say that you feel that you are entitled to reimbursement for this charge since you were at the mercy of the doctors that were involved in these procedures in the beginning. The Plan denied your request. The Plan says you received this service from a provider who chose not to receive Medicare funds.  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 covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the surgical removal of an implant body (D6100) provided on August 17, 2021 by a Medicare opt out provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided July 13, 2021.  

You asked the Plan to pay for the non-emergency ambulance transport. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says criteria for a non-emergency ambulance transport are not met.  

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   

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 non-emergency ambulance transport. Our reviewer says that the non-emergency transportation provided on July 13, 2021, was not medically necessary. Our physician reviewer found based on the documentation provided, transportation via ambulance from the hospital to a long-term care facility was not medically necessary.    

The enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport. Transportation could have been provided by other means (stretcher van) without endangering the enrollee's condition.  

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 non-emergency ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periapical first radiographic image (D0220), provided on September 23, 2021  

You asked the Plan to pay for the periapical first radiographic image. You say that the service was medically necessary. The Plan denied your request. The Plan says this is 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 pay for the periapical first radiographic image (D0220), provided on September 23, 2021
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on September 14, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the laboratory services. You say that you were not aware that a referral was needed for lab work. You also say that you cannot afford this bill. The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an OON provider.  

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 laboratory services provided on September 14, 2021 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 second round of Repetitive Transcranial Magnetic Stimulation (rTMS) treatment.  You asked the Plan to pre-approve additional rTMS services. You say that a second round of this procedure is medically necessary. The Plan denied your request. The Plan says the Medicare criteria for coverage have not been satisfied as the patient has not shown a 50% worsening of symptoms.  The Plan follows Medicare rules. Medicare rules say that for repeat rTMS services to be covered the enrollee must show a 50% worsening of symptoms.  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 additional rTMS services. Our reviewer says that the requested procedure is not medically reasonable and necessary for the enrollee's condition according to Medicare rules. Our physician reviewer found based on the information provided, this patient does not meet the clinical criteria for the repeat use of rTMS therapy.  Specifically, he has not shown a relapse/worsening of his depression by 50% based on the standardized rating scales. He continues to show depression but not at the severity that he was at the time that he initially had the treatment for rTMS.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional rTMS services have not been met. Therefore, we decided that the Plan does not have to pre-approve a second round of Repetitive Transcranial Magnetic Stimulation (rTMS) treatment.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an x-ray provided on May 20, 2021.  You asked the Plan to waive the copayment for an x-ray. You say that you do not understand the $15 charge for the x-ray because you already paid the $45 copayment for the specialist visit. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for x-ray services.      You have been asked to pay a $15 copayment for an x-ray. An x-ray falls within the outpatient diagnostic tests and therapeutic services and supplies 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 an x-ray provided on May 20, 2021.
Appeal type: Transportation
Decision: Favorable

 We decided that the Plan has to pay for ambulance service, conventional air services, transport, one way (fixed wing) (A0430) and fixed wing air mileage (A0435) provided on July 9, 2020.  You asked the Plan to pay for ambulance service, conventional air services, transport, one way (fixed wing) (A0430) and fixed wing air mileage (A0435). You say that air ambulance transport was medically necessary. The Plan denied your request. The Plan says that air ambulance transport was not medically necessary.  The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate.   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 ambulance service, conventional air services, transport, one way (fixed wing) (A0430) and fixed wing air mileage (A0435). Our reviewer says that ambulance service, conventional air services, transport, one way (fixed wing) (A0430) and fixed wing air mileage (A0435) was medically necessary. Our physician reviewer found that the documentation prior to transport does support that the enrollee suffers from an illness or injury that contraindicates transportation by any means other than ambulance. The enrollee required IV medications that needed to be continued up until consultation for possible kidney/heart transplant was made. The documentation does support that the enrollee's condition was such that the time needed to transport a patient by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health. The long ground travel (Portland, Oregon to Los Angeles, California) would have been far too long to transport a potentially unstable patient. Air transport is supported. The documentation does support that the transferring hospital did not have adequate facilities to provide the medical services needed by the enrollee. Transplant services were not available at the sending hospital.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, conventional air services, transport, one way (fixed wing) (A0430) and fixed wing air mileage (A0435) have been met. Therefore, we decided that the Plan has to pay for ambulance service, conventional air services, transport, one way (fixed wing) (A0430) and fixed wing air mileage (A0435) provided on July 9, 2020.   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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided on August 16, 2021.  You asked the Plan to pay for the self-administered drugs. You say that the hospital handed you the medication. You also say that you cannot afford to pay some of these bills. The Plan denied your request. The Plan says self-administered drugs are not covered while you are in the hospital.  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 pay for the self-administered drugs provided on August 16, 2021.   Benefits for the self-administered drugs 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Hymovis (J7322) injections.  You asked the Plan to pre-approve Hymovis. You say that the requested injections are medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs.  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 Hymovis. Our reviewer says that Hymovis injections are not medically necessary. Our physician reviewer found the provided docuemntation does not indicate that the enrollee has tried and failed the required drugs, Euflexxa, Supartz FX, Durolane, and Gelsyn-3. The reviewer also found that the there is no indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the requested drug is not medically necessary as the step therapy critiera have not been met.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hymovis have not been met. Specifically, the file does not indicate that the enrollee has tried and failed the required drugs. Therefore, we decided that the Plan does not have to pre-approve Hymovis (J7322) injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued medical care and services to be provided by an OON ophthalmologist.  You asked the Plan to pre-approve continued OON care. You say that this provider performed your surgery to treat a tumor in your eye in 2013 and has monitored your condition ever since. You see this provider every six months and they are familiar with your history and condition. The Plan denied your request. The Plan says they have agreed to approve one transitional visit with this out-of-network provider, but it is not medically necessary to continue care with this physician beyond this visit. It is safe to continue your care with an in-network provider.  Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.   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 OON care. Our reviewer says that continued care with the out-of-network provider is not medically necessary beyond what was approved by the Plan. Our physician reviewer found the record indicates that you have a history of ocular melanoma in 2013 that is stable and that there are no visual complaints. Documentation shows that the Plan has approved one transition visit. The records provided do not establish the medical necessity for continued out-of-network care beyond this visit. The record does not establish that you are receiving active treatment for the melanoma or its sequelae. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied; the requested service is not recommended.  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 OON care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued medical care and services to be provided by an OON ophthalmologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power options and related accessories.  You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says since the beneficiary does not require a power tilt seating system, the specific wheelchair with multiple power options that is being requested is not medically reasonable and necessary.  The Plan follows Medicare rules. Medicare rules say that a group 3 wheelchair with multiple power options is subject to the criteria listed 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 a group 3 power wheelchair with multiple power options. Our reviewer says that the requested group 3 wheelchair with multiple power options is not medically reasonable and necessary based on the criteria rules. Our physician reviewer found the treating medical physician documentation does not reveal that the patient needs is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or utilizes intermittent catheterization for bladder management, or needs a power seating system to manage increased tone or spasticity. Furthermore, the treating medical physician progress notes do not indicate that the patient has a mobility deficit from a Group 3 qualifying diagnosis. As a result, since the requested wheelchair does not meet Medicare coverage criteria, the related accessories are not medically reasonable and necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a group 3 power wheelchair with multiple power options have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power options and related accessories.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve use of Opdivo and Yervoy.  You asked the Plan to pre-approve Opdivo and Yervoy. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for these drugs is correct, because the enrollee's cancer progressed on Keytruda and Tecentriq requiring a change in therapy.  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 Opdivo and Yervoy. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of Opdivo and Yervoy. Our physician reviewer found the Food & Drug Administration (FDA) has not stated that Opdivo and Yervoy are approved for the enrollee's condition. The requested use of Opdivo and Yervoy are not supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo and Yervoy have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Opdivo and Yervoy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for autogenous grafting procedure (D7295), oral drugs/medicaments (D9630), anesthesia (D9219), and a lesion excision (D7413) provided by an opt-out provider on August 3, 2021.  You asked the Plan to pay for autogenous grafting procedure, oral drugs/medicaments, anesthesia, and a lesion excision. You say that these services were an emergency. The Plan denied your request. The Plan says the rendering physician is an opt-out provider.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.     The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. The rendering physician is an opt-out provider until January 1, 2023. Therefore, we decided that the Plan does not have to pay for autogenous grafting procedure (D7295), oral drugs/medicaments (D9630), anesthesia (D9219), and a lesion excision (D7413) provided by an opt-out provider on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient office visit (99203) radiologic examination, spine, lumbosacral (72100) radiologic examination, knee (73560) provided August 2, 2021.  You asked the Plan to pay for the chiropractic services. You say that you are appealing the denial of the chiropractic services. The Plan denied your request. The Plan says these services are not covered when rendered by a chiropractor  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.         The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99203) radiologic examination, spine, lumbosacral (72100) radiologic examination, knee (73560) provided August 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 23, 2021, to July 26, 2021.  

You asked the Plan to pay for acute inpatient hospital care. You say that the services should be covered. The Plan denied your request. The Plan says the services were not medically reasonable or necessary.  

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the provided documentation indicates that the enrollee was stable prior to and during their hospital stay. The reviewer also found that there was insufficient support made in the documentation that the enrollee would have required hospital services that would likely cross 2 midnights for dialysis and post-op monitoring.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Specifically, the file shows that the enrollee was stable prior to their admission. As such, it could not have been expected that the enrollee would have required hospital services that would likely cross 2 midnights. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 23, 2021, to July 26, 2021.