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

We decided that the Plan does not have to pre-approve Tecentriq for the enrollee.
You asked the Plan to pre-approve Tecentriq. You say that this is medically necessary for the enrollee. The
Plan denied your request. The Plan says that the clinical value and effectiveness of Tecentriq to be used in
combination with Cabometyx, in the setting of castrate resistant prostate cancer have not been demonstrated in
the peer-reviewed 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 Tecentriq. Our reviewer says that
Tecentriq is not medically reasonable and necessary. Tecentriq is not FDA-approved for the enrollee's
diagnosis. The use of Tecentriq is not 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 does not meet criteria for coverage of Tecentriq.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Tecentriq have not been met. Therefore, we decided that the Plan does not have
to pre-approve Tecentriq for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for GeneSight Psychotropic test (CPT code 81479) provided to
the enrollee on July 12, 2021.
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request.
The Plan says you are requesting reimbursement for the amount that is paid by Medicare for the GeneSight
Psychotropic Multigene test, a test they did not perform. The Plan states the claim did not include the Z code as
required by Article A58324. The Plan states GeneSight Psychotropic has not been shown to be useful, is not
considered medically necessary and appropriate, is not covered by Medicare and cannot be approved.
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 testing. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found Zoloft had been tried and failed the patient, according to the records. GeneSight Psychotropic
Multigene testing was requested. GeneSight Psychotropic has not been shown to be useful or lead to
significantly improved outcomes compared to standard testing and treatment based on current high-quality
evidence and is not considered medically necessary and appropriate at this time.
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 testing have not been met. Therefore, we decided that the Plan does not have
to pay for GeneSight Psychotropic test (CPT code 81479) provided to the enrollee on July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on August 25, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for office visit. You say that the enrollee's referral to see this doctor was approved. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan 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 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 an office visit provided on August 25, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions (D7210) for teeth #s 10, 11, and 12 provided
on October 21, 2021.
You asked the Plan to pay for the extractions. You say that this is the first time you have used your dental
insurance. You also say that you are trying to afford dentures. The Plan denied your request. The Plan says
there is a $2,000 allowance every year. The Plan also says that the maximum allowance has been exhausted.
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 and extractions are listed as covered,
the maximum allowance of $2,000 has been exhausted. The record shows that the Plan paid $600 for services
on September 23, 2021, $600 for services on September 30, 2021, $340 for services on October 7, 2021, $360
for services on October 14, 2021, and $80 for services received on the date of service in this case. $600 + $600
+ $360 + $360 + $80 = $2,000. The contract also says that you are responsible for any amount over and above
the allowance amount. Therefore, we decided that the Plan does not have to pay for the extractions (D7210) for
teeth #s 10, 11, and 12 provided on October 21, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for ultrasonic guidance for needle placement (76942 x 2)
provided from August 11, 2021, to August 13, 2021.
You asked the Plan to pay for the ultrasonic guidance for needle placement. You say that the services were
medically necessary. 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 pay for the ultrasonic guidance for needle
placement. Our reviewer says that the ultrasonic guidance for needle placement is not considered medically
reasonable and necessary in this case. Our physician reviewer found the provided documentation does not
support that ultrasound guidance was needed for this procedure that typically does not require more than
manual anatomic discovery of the markers to safely place the needle into the trochanteric bursa at the iliotibial
(IT) band. The reviewer found that there was no nearby joint space or other obstruction or risk for this area of
the body to justify the ultrasound. Therefore, this request for ultrasound guidance will be considered 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 ultrasonic guidance for needle placement have not been met. Specifically,
the file shows there was no nearby joint space or other obstruction or risk for this area of the body to justify the
ultrasound. Therefore, we decided that the Plan does not have to pay for ultrasonic guidance for needle
placement (76942 x 2) provided from August 11, 2021, to August 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care.
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary.
The Plan denied your request. The Plan says the request is not medically necessary because the records
received show that your condition has improved, and you are no longer a threat to yourself or others.
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 mental health care. Our
physician reviewer found you do not meet the criteria for January 28, 2022, forward as you were not shown to
be a danger to yourself or others. You were not showing any auditory or visual hallucinations and were
cooperative/compliant with treatment while not showing any threats the 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 mental health care have not been met. Therefore, we decided that the
Plan does not have to pre-approve inpatient mental health care.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing services of a registered nurse (G0299), and skilled nursing services of a licensed practical nurse (LPN) (G0300 x 4).

You asked the Plan to pre-approve home health services. You say that the requested services are medically necessary. The Plan denied your request. The Plan says you have not had new medications, a new condition or a recent hospital stay. The Plan also says that the requested services are not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 home health services. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found the provided documentation indicates that the enrollee does not have documented skilled nursing needs (i.e. IVs, complex wound care, new ostomy). The reviewer also found that the enrollee has an available caregiver. Therefore, the reviewer found the requested home health skilled nursing services are not shown to be medically necessary or reasonable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Specifically, the file does not indicate that you have documented skilled nursing needs. Therefore, we decided that the Plan does not have to pre-approve skilled nursing services of a registered nurse (G0299), and skilled nursing services of a licensed practical nurse (LPN) (G0300 x 4).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy with biopsy (45380) provided on August 25, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $300 copayment per visit, per provider, per day for surgery performed in an outpatient hospital setting.
You have been asked to pay a $300 copayment for the surgery performed in an outpatient hospital setting. 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 colonoscopy with biopsy (45380) provided on August 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary based on IRF criteria.
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for Coronavirus (COVID-19) infection, new onset atrial fibrillation and new onset diabetes.
Medical problems are stable. There are no complex nursing or rehabilitation needs.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not
a reasonable expectation that this enrollee 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment of the extraspinal
region and the electrical stimulation provided on August 9, 2021.

You asked the Plan to pay for the chiropractic manipulative treatment of the extraspinal region and the
electrical stimulation. You say that you would like the plan to reconsider their denial. The Plan denied your
request. The Plan says the services rendered are not a covered benefit.

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 that is covered by the Plan.
Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment of the
extraspinal region and the electrical stimulation provided on August 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a Coflex device and inpatient admission

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of the health problem.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy. 

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 insertion of a Coflex device and inpatient admission
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on
October 15, 2021.
You asked the Plan to pay an additional amount for eyeglasses. The Plan denied your request. The Plan says
the Plan has upheld denial of payment issued in the amount greater than the $150 allowance as it is accurate per
her 2021 Evidence of Coverage. The $150 eyewear benefit allowance was exhausted with this purchase, and
you paid your share of $379 at the time of service.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the Plan paid the eyewear benefit allowance of
$150, and you are responsible for the difference. Therefore, we decided that the Plan does not have to pay an
additional amount for eyeglasses provided on October 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency
transport (A0429) and ground mileage (A0425) provided on May 6, 2021.
You asked the Plan to pay for the transportation services. You say that this is not a duplicate claim. The Plan
denied your request. The Plan says this was a duplicate claim.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would
endanger the patient's health. 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 transportation services.
Our reviewer says that the transportation services are not medically necessary. Our physician reviewer found
the reviewer found that the enrollee's presenting symptoms do not meet prudent layperson criteria for
emergency care. The reviewer found that the documentation does not support that other means of transport
were contraindicated for the enrollee. There was no indication the patient could not travel in a non-emergent
transport vehicle. The reviewer found that the enrollee did not require or receive any treatment during the
transport. The reviewer also says that the documentation does not support that the ambulance transport on May
6, 2021 was medically reasonable and necessary 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 the transportation services have not been met. Specifically, the file does not
support that other means of transport were contraindicated for the enrollee. Therefore, we decided that the Plan
does not have to pay for the ambulance service, basic life support, emergency transport (A0429) and ground
mileage (A0425) provided on May 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), intraoral x-ray
(D0220), bitewing x-rays (D0274) and cleaning (D1110) provided on September 7, 2021, by an out-of-network
provider.
You asked the Plan to pay for the out-of-network dental care. You say that you did not know you needed to see
a network dentist. The Plan denied your request. The Plan says the provider in question is not part of the Plan's
network; out-of-network dental care is 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. Preventative and
comprehensive dental services are only covered when received from a participating provider.
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received out-ofnetwork
are not covered under this benefit. Documentation shows that the provider in this case is not part of the
Plan's specified dental vendor network. Therefore, we decided that the Plan does not have to pay for the
periodic oral evaluation (D0120), intraoral x-ray (D0220), bitewing x-rays (D0274) and cleaning (D1110)
provided on September 7, 2021, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. You can safely receive the services you need in an alternate setting.

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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 you 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and
services provided September 11, 2021, to September 14, 2021.
You asked the Plan to waive the copayment for the inpatient hospital admission and services. You say that you
are on a fixed income and cannot afford the cost. The Plan denied your request. The Plan says the copayment
has been applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250
copayment per day for days 1-3 of inpatient hospital care.
You have been asked to pay a total of $750 ($250 copayment x 3 days = $750) for the inpatient hospital
admission and services. The inpatient hospital admission and services falls 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 waive the copayment for the inpatient hospital admission
and services provided September 11, 2021, to September 14, 2021.