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

We decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac (SI) joint. 
 
You asked the Plan to pre-approve radiofrequency ablation to the SI joint. You say that this procedure is 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested 
procedure is considered experimental/investigational. 
 
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 radiofrequency ablation to the SI joint. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that according to the literature, sacral lateral nerve branch blocks 
and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered 
experimental and investigational.  Radiofrequency ablation for denervation, whether performed using 
traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, 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 radiofrequency ablation to the SI joint have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac (SI) joint.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services from April 8, 2021 
to May 7, 2021. 
 
You asked the Plan to pay for the skilled nursing facility (SNF) services. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the services received are not medically 
necessary.

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 pay for the skilled nursing facility (SNF) services. 
Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee 
required supervision for transfers and to walk 50 feet. The enrollee was independent with eating and 
hygiene/grooming. The documentation supports that the enrollee no longer qualified for SNF coverage. The 
enrollee did not have documented skilled nursing or skilled therapy needs.  Daily skilled services were not 
required to establish a maintenance program or to prevent deterioration of 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 skilled nursing facility (SNF) services have not been met. Therefore, we 
decided that the Plan does not have to pay for the skilled nursing facility (SNF) services from April 8, 2021 to 
May 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the dialysis and etelcalcetide injection provided from January 3, 2021, through January 30, 2021.

You asked the Plan to waive the coinsurance for the dialysis and etelcalcetide injections. You say that you are on a fixed income and you cannot afford to pay the big bill. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare-covered outpatient dialysis treatments and 20% coinsurance for each Medicare-covered Part B drug. 

You have been asked to pay a total of $1,016.60 for the dialysis and etelcalcetide injections.

The dialysis falls within the "Services to Treat Kidney Disease" benefit category. The etelcalcetide injection 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 dialysis and etelcalcetide injection provided from January 3, 2021, through January 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for treatment with Renflexis (Q5104) provided on June 14, 2021.

You asked the Plan to waive the coinsurance for Renflexis. You say that you have met your annual maximum out-of-pocket. The Plan denied your request. The Plan says the correct coinsurance was applied.

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. 

In this case, the Plan has documented that you did not reach your annual maximum out-of-pocket until a subsequent date of service (August 9, 2021). Therefore, you have been asked to pay $386.10, or 20% of the Medicare-allowed charge of $1,880.48, for Renflexis provided on June 14, 2021. Renflexis 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 treatment with Renflexis (Q5104) provided on June 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy with biopsy (45380) 
provided on April 26, 2021. 
 
You asked the Plan to waive the copayment for a colonoscopy with biopsy. You say that you were not told of 
the copayment in advance. The Plan denied your request. The Plan says the correct copayment was applied. 
 
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 each Medicare-covered visit to an outpatient hospital facility.  
 
You have been asked to pay a $250 copayment for a colonoscopy with biopsy. A colonoscopy with biopsy falls 
within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers" 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 a colonoscopy with 
biopsy (45380) provided on April 26, 2021.  

Your complaint about not receiving information in advance from the provider about your cost-sharing 
responsibilities is not a valid appeal for medical coverage. This part of your complaint is a grievance that must 
be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Zirabev.

You asked the Plan to pre-approve Zirabev. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that the criteria for coverage have not been met.

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 Zirabev. Our reviewer says that the requested drug is medically reasonable and necessary. Our physician reviewer found the enrollee has been diagnosed with advanced stage III/IV Mullerian cancer. In this case, first line therapy with carbo/taxol and Zirabev. The requested drug regimen of Zirabev is supported by the National Comprehensive Cancer Network. Therefore, the requested drug regimen is 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 Zirabev have been met. Therefore, we decided that the Plan has to pre-approve Zirabev.

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 pre-approve pembrolizumab (Keytruda).

You asked the Plan to pre-approve Keytruda. You say that the guidelines support combined chemotherapy and immunotherapy. 
The Plan denied your request. The Plan says the enrollee may be at more risk of side effects with little benefit to Keytruda.

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 physician reviewer found that the requested use of Keytruda is not FDA-approved with a PDL1 of 0%. The requested use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve pembrolizumab (Keytruda).
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 from June 4, 2021, to June 8, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital admission. You say that you would like 
the remaining cost covered. 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 $325 
copayment each day for days 1 - 5 each time you are admitted for Medicare-covered hospital care. 

You have been asked to pay a total of  $1,300 ($325 copayment x 4 days =$1,300) for the inpatient hospital 
admission. The inpatient hospital admission 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 from 
June 4, 2021, to June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided on July 13, 2021, to July 22, 2021. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says you did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider 
with the Plan. The Plan had network providers available who could have provided the items/services at issue in 
this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require 
the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician 
services provided on July 13, 2021, to July 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on May 27, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the drug testing. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the drug testing provided on May 27, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Nivestym for the enrollee. 
 
You asked the Plan to pre-approve Nivestym. You say that Nivestym is not being requested as part of a clinical 
trial. The Plan denied your request. The Plan says that that this is a routine cost of a clinical trial and not 
covered by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials.  
 
We looked at the file and Medicare rules. Only routine costs of the trial itself and treatment of complications 
from the trial are paid by Original Medicare. Treatment of symptoms of the underlying condition are not 
considered routine costs of the trial and would be covered by the Plan. Nivestym is being requested for 
treatment of symptoms of the underlying condition. Based on this information, we decided that Medicare rules 
for coverage of Nivestym have been met. Therefore, we decided that the Plan has to pre-approve Nivestym 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: Favorable

We decided that the Plan has to waive the coinsurance for the hospital bed provided on June 8, 2021. 
 
You asked the Plan to waive the coinsurance for the hospital bed. You say that you have Medicaid cost share 
protection and no deductibles or coinsurance. The Plan denied your request. The Plan says that you have been 
asked to pay the correct cost-sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $0 copayment for in-network durable medical equipment.  
 
The Plan says you must pay a $14.91 coinsurance for the hospital bed. Based on the Plan contract, however, 
you cannot be asked to pay more than a $0 copayment for the hospital bed. Therefore, we decided that the Plan 
has to waive the coinsurance for the hospital bed provided on June 8, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an osteogenesis stimulator (E0748) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an osteogenesis stimulator. You say that this service is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says there are in-network providers who 
are available to fulfill this request. 
 
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 
an osteogenesis stimulator (E0748) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the complete series x-ray (D0210) 
provided on February 24, 2021. 
 
You asked the Plan to pay the in network rate for the complete series x-ray. You say that you called prior to the 
date of service to make sure that the provider you were seeing was in network. You say that you received a bill 
that was processed as out of network. You also say that the services should be covered as in network. The Plan 
denied your request. The Plan says complete series x-ray is not listed as a covered service. 
 
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 complete series x-ray is not among 
those covered under this benefit, regardless of the provider's network status. Therefore, we decided that the 
Plan does not have to pay the in network rate for the complete series x-ray (D0210) provided on February 24, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy
assistant on November 27, 2019.

You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted
providers at the preferred provider rate if services are not available in the service area. You say that
the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request.
The Plan says the records do not support the service billed.

The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA)
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they
do not meet the qualifications of a therapist.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the physical therapy services have not been met. As such, PTA services cannot be paid incident to
this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical
therapy services provided by a physical therapy assistant on November 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on May 11, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you would like to appeal this service. The Plan denied your request. The Plan says this service exceeds the maximum allowed per period.
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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on May 10, 2021 and your problem focused limited oral evaluation
(D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem
focused limited oral evaluation (D0140) provided on May 11, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3.

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 step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has primary osteoarthritis of the knee. He has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, Gelsyn-3 is not reasonable or medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3.