Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for IRF care have not been met because the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient stay provided from
January 18, 2021, through January 22, 2021.
You asked the Plan to waive the copayment for the inpatient stay. The Plan denied your request. The Plan says you were in the hospital for four (4) days, and you are responsible for the $1,400 copayment.
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 $350 per day for days 1-5 for inpatient hospital care.
You have been asked to pay $350 per day for the inpatient stay. The inpatient stay 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 an inpatient stay provided from January 18, 2021, through January 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extraction of numerous teeth.
You asked the Plan to pre-approve dental extraction of numerous teeth. You say that it is medically necessary to have this procedure performed. The Plan denied your request. The Plan says this is not 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. The Plan covers dental extraction of numerous teeth when the services are medically necessary and reasonable. We looked at the file and Medicare rules. In this case, the requested dental services are to be performed by an out-of-network provider. According to the Plan's contract, dental services must only be performed by an in-network provider. Based on this information, we decided that the Plan's rules for coverage of dental extraction of numerous teeth have not been met. Therefore, we decided that the Plan does not have to pre-approve dental extraction of numerous teeth.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 15, 2020.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transitional care management services provided on
September 29, 2020, by an OON provider.
You asked the Plan to pay for the transitional care management services. You say that you were out of the area
when you went to the hospital. The Plan denied your request. The Plan says the provider is out-of-network.
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.
Therefore, we decided that the Plan does not have to pay for the transitional care management services
provided on September 29, 2020, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq.
You asked the Plan to pre-approve Tecentriq. You say that the medication 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. 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 Tecentriq. Our reviewer says that the medication is not medically necessary. Our physician reviewer found carbo/taxol/avastin and tecentriq is approvable as first line metasttaic adenoca lung. However, we do not know if metastasis is neuroendocrine cancer or adeno cancer. Thus, biopsy is needed before the medication can be approved. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Tecentriq have not been met. Therefore, we decided that the Plan does not have to pre-approve Tecentriq
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a back brace (L0650), provided on December 19, 2020, by an out-of-network provider.
You asked the Plan to pay for a back brace. You say that the item was medically necessary. The Plan denied your request. The Plan says there was no face to face evaluation, physical examination or imaging demonstrating medical necessity. The enrollee was contacted by an unsolicited outreach telephone call.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of a back brace have not been met. Therefore, we decided that the Plan does not have to pay for a back brace (L0650), provided on December 19, 2020, by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee surgery.
You asked the Plan to pre-approve knee surgery. 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 knee surgery. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the
medical necessity of this request as an exception. Therefore, the request for arthroscopy, right knee, surgical
meniscectomy is not medically reasonable or 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 knee surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve knee surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for urgent care medical services provided on October 28, 2019,
by an OON provider.
You asked the Plan to pay for urgent care medical services. You say that you would like these claims
reprocessed for medical necessity. The Plan denied your request. The Plan says there was no prior
authorization received for services rendered by an OON 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 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 urgent care medical services provided on October
28, 2019, by an OON provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90853) provided from December 1, 2020, to December 17, 2020, by an out of network (OON) provider.

You asked the Plan to pay for OON psychotherapy services. You say that this was medically necessary. The Plan denied your request. The Plan says this was not authorized.

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 psychotherapy services (90853) provided from December 1, 2020, to December 17, 2020, by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0425, A0429) received November 4, 2020.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you reside on the third floor and were not able to walk down the stairs. You needed to get to the hospital. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $350 copayment for Ambulance Services. You have been asked to pay a $350 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance Services 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 ambulance transportation (A0425, A0429) received November 4, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for laboratory services provided by an out-of-network provider on
December 27, 2020.
You asked the Plan to pay for the laboratory services. You say that authorization is not obtained for emergency
room visits and the medical records support the emergency room visit. The Plan denied your request. The Plan
says that prior authorization was required but not obtained.
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of
immediate medical attention would result in serious jeopardy to their health.
We decided that this case does meet prudent layperson criteria for emergency care. The laboratory tests were
provided during an emergency room visit to evaluate and treat an emergent medical condition. A prudent
layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical
care to seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for
laboratory services provided by an out-of-network provider on December 27, 2020.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose CT scan of the lungs for lung cancer screening for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria as they are actively symptomatic, with an ongoing productive cough and ronchi on exam.
The Plan must follow Medicare rules. The rules say that a low dose CT scan of the lungs is covered for enrollees between 55 and 77 years old. The file shows that the enrollee is 50 years old and outside of the age range for coverage of this scan. Based on this information, we decided that Medicare rules for coverage of the scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a low dose CT scan of the lungs for lung cancer screening for the enrollee
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular screening testing provided on October 19, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular-respiratory disease.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular screening testing provided on October 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Hizentra at a dosage level of 550 milligrams per kilogram per week (mg/kg/wk).
You asked the Plan to pre-approve Hizentra. You say that the enrollee has benefitted tremendously from subcutaneous immune globulin, so you are requesting a dose increase in order to adequately control and manage the enrollee's symptoms. The Plan denied your request. The Plan says the denial of authorization for this drug dosage is correct, because this request exceeds the FDA recommended dosage range of 200 to 400mg/kg/wk.
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 Hizentra. Our reviewer says that the enrollee does not meet the criteria for use of Hizentra at the requested dosage level. Our physician reviewer found the requested dosage level of Hizentra is not FDA approved for the enrollee's diagnosis. The product label indicates that if symptoms worsen on a 400mg/kg/wk dosage, consider reinitiating therapy with intravenous immune globulin and discontinuing Hizentra. The dosing sought in this case exceeds the limit of 400mg/kg/wk. The requested dosage is not supported by one of the major drug compendia or by research
appearing 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 Hizentra have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Hizentra at a dosage level of 550 milligrams per kilogram per week (mg/kg/wk).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telephone evaluation and management service provided on January 12, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the telephone evaluation and management service. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 telephone evaluation and management service
provided on January 12, 2021 by an out of network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first 15 minutes of deep sedation/general anesthesia (D9222), each subsequent 15 minute increment of deep sedation/general anesthesia (D9223), consultation (D9310), and therapeutic parenteral drugs (D9612) provided on December 22, 2020.
You asked the Plan to pay for the deep sedation/general anesthesia, consultation, and therapeutic parenteral drugs. You say that you were told that all of the dentists at the facility you went to were authorized providers. You also say that you were told all of the services would be covered. The Plan denied your request. The Plan says these services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first
15 minutes of deep sedation/general anesthesia (D9222), each subsequent 15 minute increment of deep
sedation/general anesthesia (D9223), consultation (D9310), and therapeutic parenteral drugs (D9612) provided
on December 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the high frequency chest wall oscillation device provided on
August 7, 2020.
You asked the Plan to pay for the provided item. You say that this is a Medicare-covered device. The Plan
denied your request. The Plan says claims without history will be denied as non-covered.
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.
We looked at the file and the rules. The medical records do not include well-documented failure of standard
treatments to adequately mobilize retained secretions. Based on this information, we decided that the Medicare
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the high
frequency chest wall oscillation device provided on August 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services rendered on January 11, 2021.
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 procedure code 20553 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 20553 is injection(s); single or multiple trigger point(s), 3
or more muscles.
We find that CPT code 20553 is not supported in the medical record. Specifically, there is no documentation of
trigger point injections to three or more muscles. 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 pay for the
injection services rendered on January 11, 2021.