Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the injections provided on April 9, 2021 
and April 16, 2021. 
 
You asked the Plan to waive the coinsurance for injection, ferumoxytol, for treatment of iron deficiency anemia 
(Q0138). You say that you cannot afford the copayments. The Plan denied your request. The Plan says you 
were charged this coinsurance 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay 20% coinsurance for injection, ferumoxytol, for treatment of iron deficiency 
anemia (Q0138). The injection, ferumoxytol, for treatment of iron deficiency anemia (Q0138) falls within the
Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the injections provided on April 9, 2021 and April 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ambulance services.
You asked the Plan to pre-approve ambulance services. You say that these services are medically necessary. The Plan denied your request. The Plan says that a physician's office is not a covered destination.
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 pre-approve ambulance services. Our reviewer says that ambulance services are not medically reasonable and necessary for the enrollee. The documentation does not support that other means of transport (such as stretcher van) are contraindicated for you. The documentation does not support that you need the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. Our physician reviewer found that your condition does not meet Medicare criteria for ambulance services. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve ambulance services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 18 physical therapy visits.
You asked the Plan to pre-approve 18 physical therapy visits. You say that the records provided support the need for the requested physical therapy visits. The Plan denied your request. The Plan says the requested physical therapy visits are not medically necessary. The Plan says that a home exercise program should help the enrollee reach her goals.
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 18 physical therapy 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 additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy and 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 by or under the supervision of a therapist. The enrollee has been instructed in a home exercise program. The requested services are not part of a maintenance program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 18 physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 18 physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy (PBT).
You asked the Plan to pre-approve PBT. You say that the records provided support the need for PBT. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that there is no biopsy-confirmed diagnosis that the legion is a cancer amenable to PBT.
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 PBT. Our reviewer says that PBT is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence that proton therapy is needed over other accepted treatments. There is no plausible reason that proton therapy would be more beneficial than standard therapy for this particular 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 PBT have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy (PBT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6533 that were issued on February 1, 2021.
You asked the Plan to pay for the compression stockings. You say that you feel that the stockings should be covered. The Plan denied your request. The Plan says compression stockings are not a covered item because they do not meet the definition of a surgical dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6533 that were issued on February 1, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (77061) provided to the enrollee on
February 15, 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 this is an invalid procedure code for this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 77061 is not supported in the medical record. Specifically, this code has a status
indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for
Medicare purposes. 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 radiology services (77061)
provided to the enrollee on February 15, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on March 22, 2021.
You asked the Plan to pay for critical care services. You say that this was billed correctly. The Plan denied your request. The Plan says this code is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent on critical care is not documented. Based on this information, we decided that Medicare rules for coverage of critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided on March 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the vertiflex device is experimental. More research is needed to show safety and 
efficacy of the device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on June 13, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the services provided. You say that it should not matter where you go as it is still medical equipment. The Plan denied your request. The Plan says you must receive your care from a network 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 file shows that you received a walker on the date of service at issue. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided on June 13, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor kit.
You asked the Plan to pre-approve a Freestyle Libre 2 sensor kit. You say that the item is 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. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses
adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle
Libre 2 sensor kit have not been met. Therefore, we decided that the Plan does not have to pre-approve a
Freestyle Libre 2 sensor kit.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve carboplatin, Dexamethasone Sodium Phosphate, Famotidine, Diphenhydramine HCL and Braxane.
You asked the Plan to pre-approve carboplatin, Dexamethasone Sodium Phosphate, Famotidine, Diphenhydramine HCL and Braxane. You say that the medications are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 carboplatin, Dexamethasone Sodium Phosphate, Famotidine, Diphenhydramine HCL and Braxane. Our reviewer says that the medications are not medically necessary. Our physician reviewer found in this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s) 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 carboplatin, Dexamethasone Sodium Phosphate, Famotidine, Diphenhydramine HCL and Braxane have not been met. Therefore, we decided that the Plan does not have to pre-approve carboplatin, Dexamethasone Sodium Phosphate, Famotidine, Diphenhydramine HCL and Braxane.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on February 8, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for lab test. You say that this claim should be appropriate paid at the Medicare allowed rate. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.
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 laboratory testing provided on February 8, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional payment for anti-reflective coating (V2750) provided on June 7, 2021.
You asked the Plan to reimburse you an additional payment for anti-reflective coating. You say that that you disagree with the denial and the service should be covered. The Plan denied your request. The Plan says you exceeded the $200 vision allowance benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that you receive up to a total of $200 every calendar year for eyeglasses, frames, lenses or contact lenses from participating network providers. We looked at the file and the Plan's rules. The records show you exhausted your $200 maximum allowed benefit. The records also show you purchased bifocal lenses for a total amount of $273. The Plan applied your $200 allowance which left you with a balance of $73. The remaining balance is your responsibility as you have reached the maximum allowed amount. Based on this information, we decided that the Plan's rules for coverage of anti-reflective coating have not been met. Therefore, we decided that the Plan does not have to reimburse you an additional payment for anti-reflective coating (V2750) provided on June 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that this is not covered under Part B.

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 Dupixent for the enrollee.  
 
Benefits for this drug 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 established patient domiciliary or rest home visit (99336) provided on May 18, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that the treatment received was medically necessary for the enrollee. You have attached the medical records for the date of service and request review of the documents and process the claim towards payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered. 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 established patient domiciliary or rest home visit (99336) provided on May 18, 2021 by an out-of-network (OON) 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 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 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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
You do 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee x-ray provided on March 16, 2021 by an out-of-network (OON) provider.
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 were rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 knee x-ray provided on March 16, 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 a medical eye exam (92004) provided on September 15,
2020.
You asked the Plan to pay for a medical eye exam. You say that you have been living out of state due to
Coronavirus. You also say you contacted your primary care physician for an out of state service and it was not
acknowledged. The Plan denied your request. The Plan says the exam would be covered only if you use a
network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan contract says that you receive one routine eye exam each calendar year. No referral is
required for an annual routine eye exam, but you must use a network provider.
We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's vision network. The
Plan covers a routine eye exam when they are received from a provider who participates in the Plan's specified
vision network. Please note, a referral was received but the start date was not until December 9, 2020, which
does not cover this date of service. Based on this information, we decided that the Plan's rules for coverage of a
medical eye exam have not been met. Therefore, we decided that the Plan does not have to pay for a medical
eye exam (92004) provided on September 15, 2020.