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

We decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device (22869 and 22870).
You asked the Plan to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device. You say that this is medically necessary. The Plan denied your request. The Plan says his is not covered.
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 the insertion of interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device in question is experimental. More research is needed for it to be considered medically necessary under Medicare rules. 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 insertion of interlaminar/interspinous process stabilization/distraction device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device (22869 and 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from September 1, 2019 through September 25, 2019.
You asked the Plan to waive the copayment for the SNF stay. You say that you were not notified about the copayment. You say that the bill is a hardship. The Plan denied your request. The Plan says the copayment 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 $0 copayment each day for days 1 to 20 and a $160 copayment each day for days 21 to 62 at an in-network provider. You have been asked to pay a $3,360 copayment for the SNF stay.
The SNF stay falls within the "Skilled Nursing Facility (SNF) 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 SNF stay provided from September 1, 2019 through September 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on September 16, 2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on April 24, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on April 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ado-trastuzumab emtansine (Kadcyla) for the enrollee.
You asked the Plan to pre-approve Kadcyla. You say that without the drug, the enrollee will have shorter time to live. The Plan denied your request. The Plan says the use of the drug for metastatic pancreatic cancer is not approved.
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 Kadcyla. Our physician reviewer found that the enrollee has metastatic pancreatic cancer. Herceptin was started, but increased disease. The requested use of Kadcyla is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-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 Kadcyla have not been met. Therefore, we decided that the Plan does not have to pre-approve ado-trastuzumab emtansine (Kadcyla) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 21, 2019.You asked the Plan to pay for the laboratory services. 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.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 laboratory services were requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for tetrahydrocannabinol capsules purchased from October 9, 2019 to
December 14, 2019
You asked the Plan to pay for tetrahydrocannabinol capsules. You say that tetrahydrocannabinol was recommended by your doctor due to the positive effects. You say that you use tetrahydrocannabinol for pain management and it should be covered and accessible through your health insurance The Plan denied your request. The Plan says tetrahydrocannabinol is not on the Flex benefit eligible items list.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for nutritional supplements. The Plan contract offers a Flex benefit that provides a supplemental benefit for the purchase of non-Medicare healthcare items. We looked at the file, Medicare rules and the Plan's rules. The file shows that tetrahydrocannabinol is not on the Flex benefit eligible items list. Therefore, we decided that the Plan does not have to reimburse you for tetrahydrocannabinol capsules purchased from October 9, 2019 to December 14, 2019
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health nursing visits.
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says you do not need a nurse for medication or wound care.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health services. Our physician reviewer found that the records do not show that skilled nursing or skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. The documentation does not reveal evidence of complex wound care, IV medications, enteral feedings or other SN need for 10 additional 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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health nursing visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on October 30, 2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered to the enrollee on December 17, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for the special pump services rendered to the enrollee on December 17, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercise provided on November 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for therapeutic exercise. You say that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that these services can be provided in-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 has network providers available who can provide 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 therapeutic exercise provided on November 5, 2019 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health care services provided from September 27, 2018 to December 30, 2018.
You asked the Plan to pay for home health care services. You say that this should be covered. The Plan denied your request. The Plan says these services were provided by a provider who does not participate in Medicare.
The Plan must follow Medicare rules. Medicare rules say that home health services are covered only when the home health agency that is providing the services to the beneficiary has in effect a valid agreement to participate in the Medicare program We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health care services have not been met. The provider you received these services from does not participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for home health care services provided from September 27, 2018 to December 30, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe cleaning provided on November 22, 2019.You asked the Plan to pay forthe cleaning. You say that you have previously been covered for 2 cleanings per year. You say that if you knew you had to pay you wouldn't have had the cleaning.The Plan denied your request. The Plan says only one cleaning is covered per calendar year.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 Plan also has a maximum benefit of 1 cleaning per calendar year. The records show that you received a cleaning on May 21, 2019, which exhausted the benefit.Therefore, we decided that the Plan does not have to pay forthe cleaning provided on November 22, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered to the enrollee from September 16, 2019 to September 30, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claims were not billed correctly.
The Plan must follow Medicare rules. The rules say that where required by law or regulation, report the Federal Information Processing Standards (FIPS) State and County Code of the place of residence where the home health service is delivered with code 85. We looked at the file and Medicare rules. The claims were not billed with the required FIPS code. 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 home health services rendered to the enrollee from September 16, 2019 to September 30, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care, typically 15 minutes (99308) provided on September 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for subsequent nursing facility care. You say that the services were provided and payment should be rendered. The Plan denied your request. The Plan says prior authorization was not requested or received and the services were not emergent in nature. Therefore, coverage criteria has 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 has network providers available who can provide 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 subsequent nursing facility care, typically 15 minutes (99308) provided on September 20, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay for the office visit rendered on August 6, 2019.
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 that procedure code 99203 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 99203 is Level 3 new patient office or other outpatient visit, typically 30 minutes. We find that CPT code 99203 is not supported in the medical record. Specifically, this code is for a new patient office visit and the file shows that the enrollee previously received an office visit from a provider at the same specialty group on July 25, 2019; therefore, a new visit does not apply. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan has to pay for the office visit rendered on August 6, 2019.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve ablation (64624).
You asked the Plan to pre-approve genicular nerve ablation. You say that this would help the enrollee's pain and quality of life. The Plan denied your request. The Plan says this is experimental.
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 genicular nerve ablation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is still considered an experimental/ investigational procedure and is the subject of on-going clinical trials. Therefore, the request is considered 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 genicular nerve ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve ablation (64624).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services.
You asked the Plan to pre-approve home health aide. You say that the enrollee needs help with all activities of daily living. The Plan denied your request. The Plan says the denial of authorization for home health aide is correct, because the enrollee is not receiving skilled services and home and therefore home health aide is not covered.
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. The rules say that custodial care services are not covered by Medicare. We looked at this physician's review, the file, and Medicare rules. The enrollee is not receiving skilled care services in the home; therefore, a home health aide is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of home health aide have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent for enrollee.You asked the Plan to pre-approve Dupixent. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Dupixent for enrollee. Benefits for Dupixentmay be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on December 3, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says documentation submitted did not indicate the provider discussed the need for the billed supply code; therefore the billed supply code cannot be verified.
The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the medical record shows that coverage criteria for the item have been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on December 3, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided from February 1, 2019 to February 28, 2019.
You asked the Plan to pay for the physical therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that therapy codes are not supported in the medical record. Specifically, claims for therapy services require functional G-code/modifier information. These services were not billed with the required functional G-code/modifier. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy services provided from February 1, 2019 to February 28, 2019.