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

We decided that the Plan does not have to pre-approve Fasenra.
You asked the Plan to pre-approve Fasenra. The Plan denied your request. The Plan says the use of the drug requires an eosinophilic phenotype.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Fasenra. Our physician reviewer found that there is no documentation that the Fasenra is FDA-approved for the enrollee's diagnosis. The records do not document that the enrollee has asthma with an eosinophilic phenotype. The use of Fasenra for asthma without an eosinophilic phenotype is not supported by one of the major drug compendia, or by clinical research that appears in a CMS-approved medical journal. 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 Fasenra have not been met. Therefore, we decided that the Plan does not have to pre-approve Fasenra.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency ambulance services (A0429) provided June 22, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that you were forced to take the ambulance ride and cannot afford the cost. The Plan denied your request. 
The Plan says you were charged this cost sharing 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 $200 copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $200 for these services. 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 emergency ambulance services (A0429) provided June 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional physical therapy services.  You asked the Plan to pre-approve additional physical therapy services. You say that the patient has only partially met his goal and will significantly benefit from continued physical therapy. You say that the patient continues to demonstrate loss of motion for cervical rotation and decreased tolerance to standing activities and 8 to 10 more visits should be covered. The Plan denied your request. The Plan says the services are not medically necessary.  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 additional physical therapy services. 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 that the treatment notes do not compare current level of function to prior level of function and the office notes do not show loss of function or objective improvement. Our reviewer says that the enrollee does not meet the criteria for the requested additional physical therapy visits.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional physical therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Photofrin.  
You asked the Plan to pre-approve Photofrin. You say that this drug will make the enrollee cancer-free. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because there is not enough support for use of Photofrin for the enrollee's condition.  
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 Photofrin. 
Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of Photofrin. 
Our physician reviewer found Photofrin is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. The requested use is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Photofrin have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Photofrin.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pay for IRF care. You say that you need inpatient rehabilitation services. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your ongoing skilled therapy needs are being met in the current skilled nursing facility.  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 pay for 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 based on the documentation provided, you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours of rehabilitative services per week with regular physician evaluation. The requested IRF care is not medically necessary 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for a diagnostic or therapeutic injection (62323) provided on June 10, 2021, by an out-of-network provider.  You asked the Plan to pay for a diagnostic or therapeutic injection. You say that you were misinformed that no authorization was needed for the services at issue. The Plan denied your request. The Plan says rules for out-of-network care have not been met.  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 a diagnostic or therapeutic injection (62323) provided on June 10, 2021, by an out-of-network provider.   Your complaint about receiving erroneous or incomplete information about the enrollee's benefits from an online resource maintained by the Plan 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: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes (G0151).  You asked the Plan to pre-approve the home health services. You say that say the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says medical necessity for the remaining home health physical therapy visits cannot established without the outcome of the initial PT evaluation and enrollee's response to the 4 follow up home PT visits.  The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 the home health services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the limited documentation provided, the health Plan's denial should be upheld. The enrollee does not have documented skilled therapy needs. As such, the requested home health physical therapy services are not 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 the home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes (G0151).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a service dog benefit (S5199).  You asked the Plan to pre-approve a service dog benefit. You say that this service is a medical necessity. You are asking the Plan for reconsideration. The Plan denied your request. The Plan says several attempts to reach the health care provider were made and the Plan was unable to receive confirmation that you meet the qualifying criteria for this benefit.  The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a service dog benefit have not been met. Specifically, we have confirmed that you do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-approve a service dog benefit (S5199).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).  You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says there is insufficient evidence of the requested procedure's efficacy.  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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the device at issue is considered experimental/investigational.  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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve use of Eylea.  You asked the Plan to pre-approve Eylea. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of bevacizumab before it will approve Eylea.  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 Eylea. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Eylea. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drug of bevacizumab. There is no documentation that this drug would likely be less effective and/or 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 Eylea have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Eylea.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (96405) provided on May 26, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not payable.  The Plan must follow Medicare rules. Medicare rules say that payment for the mentioned services is included in the global surgical payment.   We looked at the file and Medicare rules. The requested service is included in the global surgical package of the surgery performed on May 18, 2021. Separate payment cannot be made for this service. 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 the services (96405) provided on May 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Jemperli (dostarlimab).  You asked the Plan to pre-approve Jemperli. You say that you need urgent help for your cancer. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because Jemperli is used for a particular type of cancer that is not your type.  
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 Jemperli. Our reviewer says that you do not meet the Medicare criteria for the requested use of Jemperli. Our physician reviewer found Jemperli is approved only for microsatellite instability (MSI) disease; however, your disease is microsatellite stable (MSS).  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Jemperli have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Jemperli (dostarlimab).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for critical care services (procedure code 99291) provided to the enrollee on June 10, 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 the records do not support the services billed.  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 documentation does include notation of the time spent providing this service. This information is required because CPT 99291 is a time-based code. 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 critical care services (procedure code 99291) provided to the enrollee on June 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for infusion therapy (96385) provided on December 22, 2020, to December 31, 2020.  You asked the Plan to waive the copayment for infusion therapy. 
You say that you were told that you required infection fighting drugs following your discharge from the hospital. You also say that you were not told that the infusion would be so expensive. The Plan denied your request. The Plan says the copayment you are being charged is correct.     
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 $175 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges.   
You have been asked to pay a $175 copayment for each infusion therapy visit. The EOC confirms that $175 is the required copayment per visit for this service. The records show you received eight (8) infusion therapy visits, therefore your total amount owed is $1,400 ($175 x 8 visits = $1,400). Infusion therapy falls within the outpatient surgery and other medical 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 infusion therapy (96385) provided on December 22, 2020, to December 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for anesthesia services you received during outpatient eyelid surgery on June 22, 2021.  You asked the Plan to waive the deductible for the anesthesia services. You say that you didn't receive the injections on your bill that were coded with the following codes: J2704, J3010, J2250, and J7120. You said that you shouldn't have to pay for something you did not receive. The Plan denied your request. The Plan says you were assessed this deductible correctly.    
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 there is a $750 deductible which applies to outpatient surgery services.   We looked at the medical records from this surgery. The records from the surgery clearly indicate that your anesthesiologist for the procedure gave you the injections listed with the codes above. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to outpatient surgery services. 
Because these anesthesia services are part of the surgery, the deductible applies to these services as well This cost sharing is a contractual obligation that had not been met at the time the anesthesia services were received on June 22, 2021. Therefore, we decided that the Plan does not have to waive the deductible for anesthesia services you received during outpatient eyelid surgery on June 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services provided on May 3, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the primary insurer has not submitted the explanation of benefits.  The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.  The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the services provided on May 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device.  You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the device is not indicated.  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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The Vertiflex device is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that your condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device.