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

We decided that the Plan does not have to pre-approve Aduhelm for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says it has not been established that all the enrollee's symptoms can be attributed to Alzheimer's disease.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

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 drug. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the FDA-approved label states that Aduhelm is "approved under accelerated approval based on reduction in amyloid beta plaques observed in patients treated with Aduhelm." The enrollee's case file does not contain documentation of amyloid beta plaques. The magnetic resonance imaging (MRI) in this case suggests the presence of cerebrovascular disease, which is evidence of a mixed etiology for the enrollee's symptoms. The enrollee's medication list includes Namenda, which is indicated for the treatment of Alzheimer's disease (moderate to severe). Aduhelm is FDA-approved for the treatment of Alzheimer's disease in patients with mild cognitive impairment or mild dementia stage of disease. The documentation is insufficient to demonstrate that the enrollee in this case has Alzheimer's disease in patients with mild cognitive impairment or mild dementia stage of disease. Additionally, it has not been demonstrated that Aduhelm is at least as beneficial as the existing and medically appropriate alternatives that this enrollee is taking. The documentation does not support that Aduhelm would be safe and effective in this case.

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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 5 fillings provided on August 10, 2021.
You asked the Plan to pay for the dental services. You say that your plan covers a root canal that costs about $1,500. You say that the tooth in question is so thin that it could fracture. You also say that the services should be covered as their total is half of what a root canal would be. The Plan denied your request. The Plan says 2 fillings are covered per calendar year. The Plan also says that the frequency limit has been exceeded.
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 fillings are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for 2 fillings that you received on August 5, 2021. Therefore, we decided that the Plan does not have to pay for the 5 fillings provided on August 10, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an orthopedic spine consultation to be provided by an out-of-network (OON) tertiary provider.

You asked the Plan to pre-approve the OON orthopedic spine consultation. You say that you are not able to get up or walk and are experiencing pain. The Plan denied your request. The Plan says the services being requested are not urgent or emergent and are available within the enrollee's tertiary network in a timely manner. The Plan says that there is a current authorization for the requested service with the network tertiary provider. The Plan says that the enrollee's orthopedic surgery provider agrees with the plan for the enrollee to be seen by the network tertiary 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 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 orthopedic spine consultation to be provided by an out-of-network (OON) tertiary provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the take-home supply of methadone provided on August 22, 2020, by an out-of-network (OON) provider.  You asked the Plan to pay for the take-home supply of methadone. You say that the provider was not notified of the enrollee's insurance. 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 services at issue were urgent or emergent.  Therefore, we decided that the Plan does not have to pay for the take-home supply of methadone provided on August 22, 2020, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

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 bilateral primary osteoarthritis of the knee. She 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, Euflexxa 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 Euflexxa.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Feraheme 510MG/17ML vial.

You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's laboratory values indicate that the enrollee does not currently have iron deficiency anemia.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

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 medication. Our physician reviewer found the record indicates that the enrollee has a diagnosis of unspecified anemia. The record indicates that the last hemoglobin was 13.1. The record does not indicate the presence of iron deficiency or intolerance to oral iron supplementation. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The elements of the coverage criteria are not satisfied. The requested service cannot be 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 the medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Feraheme 510MG/17ML vial.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says based on Medicare guidelines, the skilled nursing facility services you are requesting do not meet the requirements for approval.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, you received oral medications. You had stable vital signs. Regarding rehabilitation services, you received physical therapy (PT), speech therapy (ST) and occupational therapy (OT). You were at stand by assist/supervision to contact guard assist level with functional mobility including gait to 100 feet with home health aide. You required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. As a practical matter, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra.
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 self-administered drugs are not covered.
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 Xiidra.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a lumbar laminectomy and will need inpatient admission after surgery. The Plan denied your request. The Plan says there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.

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 pre-approve 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 enrollee is approved for a lumbar laminectomy. The record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights. 

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. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for paramedic intercept services provided on May 30, 2021.

You asked the Plan to pay for paramedic intercept services. You say that had no control over this as the enrollee was bleeding and the ambulance was called. You say there was a guy and a girl from the ambulance company and then all of a sudden there were two other guys from another ambulance there. You say that your brother was so weak because he lost so much blood and there was blood everywhere so that they had to pick him up and carry him out to take him to the hospital. The Plan denied your request. The Plan says the paramedic intercept claim was processed correctly.

The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York. 

The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for paramedic intercept services provided on May 30, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on July 20, 2021.

You asked the Plan to waive the copayment for emergency care. You say that you cannot afford the charges. 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 $100 copayment for emergency care. 

You have been asked to pay a $100 copayment for emergency care. Emergency care falls within the emergency 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 emergency care provided on July 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the orthotic footwear and supplies you received on June 10, 2021, and August 2, 2021.  

You asked the Plan to waive the coinsurance for the orthotic footwear and supplies. You say that you are unhappy with the products you received because the shoe rubbed a hole in your toe.  You are now wearing an old shoe and you would like your money returned. 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 durable medical equipment and supplies.    

You have been asked to pay 20% coinsurance for the orthotic footwear and supplies. The orthotic footwear and supplies fall within the durable medical equipment and supplies benefit category. This cost sharing applies regardless of your satisfaction with the items received. 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 orthotic footwear and supplies you received on June 10, 2021, and August 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical services (procedure code 20245) provided to the enrollee on December 29, 2020.  

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 code cannot be separately reimbursed.  

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, we have confirmed that code 20245 is a column II code to column I code 27245. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (procedure code 20245) provided to the enrollee on December 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services you had on July 24, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that you were taken to a facility that you weren't admitted to, so you shouldn't have to pay the copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment per one-way trip for ambulance services.  You have been asked to pay a $225 copayment per one-way trip for the ambulance services. This copayment applies regardless of the reason for the transport, or the outcome of your hospital stay. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services you had on July 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving and should require only short-term acute care services that can safely be administered at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility.  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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 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 enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  The enrollee's care needs can be met at a lower level of care.  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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the anticoagulation management services you received from a cardiologist's office on March 17, 2021.  You asked the Plan to waive the copayment for the anticoagulation management services. You say that you are being charged every week and you are not going into the office. You said that you were told you would not have to pay a copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that because the allowed amount for this service ($10.23) is less than your copayment obligation, you are responsible for the full allowed 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 $35 copayment for services with a specialist.   You have been asked to pay a $35 copayment for the anticoagulation management services. Because the results of your home monitor are reviewed by the cardiologist's office, it means that the anticoagulation management services fall within the services with a specialist 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 anticoagulation management services you received from a cardiologist's office on March 17, 2021.