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

We decided that the Plan does not have to pre-approve Keytruda, Gemcitabine, Carboplatin, Ondansetron IV and Dexamethasone for the enrollee.You asked the Plan to pre-approvethese services. You say that this is medically necessary.The Plan denied your request. The Plan says that the enrollee's therapy shows recent imaging scans demonstrated progression of disease while receiving pembrolizumab therapy.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 these services. Our reviewer says that Keytruda, Gemcitabine, Carboplatin, Ondansetron IV and Dexamethasone are not medicallyreasonable and necessary for the enrollee in this case. It is not clear based on most recent CAT scan if the patient meets RECIST criteria for progression. That said he is receiving 2nd line therapy and the addition of carboplatin and gemcitabine would not be a standard therapy. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these drugs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicarerules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approveKeytruda, Gemcitabine, Carboplatin, Ondansetron IV and Dexamethasone for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foremergency care provided on September 11, 2019.You asked the Plan to waive the copayment foremergency care. You say that you cannot afford to pay the copayment.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received emergency care provided on September 11, 2019. You are asked to pay a $90 copayment for the emergency care. 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 foremergency care provided on September 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 Day Sensor.You asked the Plan to pre-approve a Freestyle Libre 14 Day Sensor. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the enrollee does not meet criteria. The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. Medicare says in order to be covered for a therapeutic CGM, patients must consistently check their blood sugar levels four or more times a day and be insulin-treated with at least three daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. The file shows that the enrollee does not consistently check their blood sugar levels at least four or more times a day and the enrollee is not insulin-treated with at least three daily injections of insulin or a Medicare-covered CSII pump. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 14 Day Sensor have not been met.Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 Day Sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered on December 26, 2018.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 31610 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 31610 is tracheostomy, fenestration procedure with skin flaps.We find that CPT code 31610 is not supported in the medical record. Specifically, there is no documentation that a tracheostomy was performed. 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 forthe services rendered  onDecember 26, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fentanyl Dis 25mcg/Hr for the enrollee.
You asked the Plan to pre-approve Fentanyl Dis 25mcg/Hr. You say that this drug is medically necessary. The
Plan denied your request. The Plan says this drug is not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Fentanyl Dis 25mcg/Hr for
the enrollee.
Benefits for Fentanyl Dis 25mcg/Hr may 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for mechanical traction therapy (97012) provided on September 13, 2019.
You asked the Plan to pay for the mechanical traction therapy. You say that this service has been helpful and helps to enhance good health in the human body. The Plan denied your request. The Plan says mechanical traction therapy is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for mechanical traction therapy (97012) provided on September 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveHydroco/Apap tablets.You asked the Plan to pre-approveHydroco/Apap tablets. You say that this drug is medically necessary.The Plan denied your request. The Plan says this drug is not covered under Medicare Part B.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-approveHydroco/Apap tablets.Benefits for Hydroco/Apap tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam (92012) provided on October 9, 2019.You asked the Plan to pay for the eye exam. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation received does not match the rendering provider.The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the eye exam have not been met. Specifically, the record submitted does not include the name or signature of the rendering provider. Therefore, we decided that the Plan does not have to pay for an eye exam (92012) provided on October 9, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on June 14, 2019.You asked the Plan to pay fortheambulance services. You say that the Plan should pay this claim.The Plan denied your request. The Plan says the claim denied due to invalid/missing pick-up zip.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes.In this case, thePoint of Pickup Zip Code is missing. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on June 14, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ED visits provided onSeptember 1, 2019, October 5, 2019 and October 14, 2019 through October 15, 2019.You asked the Plan to waive the copayment forthe ED visits. You say that you thought if you are admitted for over 24 hours you don't have to pay the copayment. You say that you were admitted each time.The Plan denied your request. The Plan says the copayments 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 $120 copayment for emergency services in an emergency room.You have been asked to pay a $120 copayment for each ED visit. The total amount you owe is $360 ($120/visit x 3 visits = $360). The ED visits fall within the "Emergency care" benefit category. The records show that you wereadmitted to outpatient observation from October 14, 2019 through October 15, 2019. This means that you have been asked to pay the correct amountbased 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 forthe ED visits provided on September 1, 2019, October 5, 2019 and October 14, 2019 through October 15, 2019.Your complaint about the Plan being fraudulentis 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services for the enrollee.You asked the Plan to pre-approvethe LTACH services. The Plan denied your request. The Plan says there is no advantage in transferring the enrollee from the current hospital.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 physician reviewer found that LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory care including intermittent BiPAP or CPAP, close fluid balance, dialysis, telemetry, surveillance laboratory studies, and therapy services. The documentation does not support that the enrollee in this case requiresservices at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.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-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for CPT code 74176 provided on September 16, 2019.
You asked the Plan to pay for CPT code 74176. You say that you would like the Plan to reconsider their denial
of payment. The Plan denied your request. The Plan says that the services are not covered as billed.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, the case file does not contain evidence that CPT code 74176 cannot
be paid as it was billed, according to Medicare rules. The file does not contain a copy of a claim that contains
the CPT code 74177 that the health plan states CPT code 74176 is bundled with. It cannot be verified that
payment for CPT code 74176 is bundled with another procedure that was billed on the same date of service.
Therefore, we decided that the Plan has to pay for CPT code 74176 provided on September 16, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe abdominal ultrasound rendered on September 12, 2019.Youasked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 76705 is not separately payable.The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claim for procedure codes 76705 and 93975. Code 76705 is a column II code with a modifier indicator of1 when billed with column I code 93975. Code 76705 was not billed with an appropriate modifier to allow for separate payment.Therefore, we decided that the Plan does not have to pay forthe abdominal ultrasound rendered on September 12, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that you do not require ongoing daily skilled therapy in an inpatient basis at this time.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup for tooth #18 and #19 (D2950).You asked the Plan to pre-approve core buildup for tooth #18 and #19. You say that the service is necessary.The Plan denied your request. The Plan says the requested service is not a covered benefit. Therefore, coverage criteria has not been met.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 pre-approve core buildup for tooth #18 and #19 (D2950).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran x-ray of the knee (73564) provided on August 5, 2019. You asked the Plan to waive the copayment forthe X-ray. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment was applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with thePlan clearly says that you must pay a $40 copayment for X-rays. You have been asked to pay a $40 copayment for the X-ray. The X-ray of the knee falls within the X-rays benefit category. This means that you have been asked to pay the correct amount basedon 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 foran x-ray of the knee (73564) provided on August 5,2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee is ready to be transferred to the LTACH for further ventilator weaning, wound care, and therapy.The Plan denied your request. The Plan says the enrollee does not meet criteria for transfer toa LTACH.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's hospital course has been complicated by pneumonia and the development of pressure sores. The enrollee appears to be tolerating ventilator weaning. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveKeytruda for the enrollee.You asked the Plan to pre-approvethese services. You say that the services are medically necessary.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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has heavily pretreatedmetastatic low grade leiomyosarcoma of the uterus. Testing of the tumor in 2016 showed it to be mismatch repair proficient. Keytruda is not FDA-approved or supported in any of the Medicare drug compendia for this diagnosis. The Keytruda is not reasonable or medically necessary or safe and effective for the enrollee at this time.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-approveKeytruda for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 Day Sensor.
You asked the Plan to pre-approve a Freestyle Libre 14 Day Sensor. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. Medicare rules also say that therapeutic CGMs are covered only when a patient has been performing four or more blood glucose testings every day and is insulin-treated with at least three or more daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. The file shows that you do not test your blood glucose levels at least four or more times a day and you are neither insulin-treated nor have a CSII pump. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 14 Day Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 Day Sensor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe Guardant360 test provided to the enrollee on January 19, 2019.You asked the Planto pay forthe test. You say that denying Guardant360 as an experimental service is in conflict with NCCN national practice guidelines for treating patients with advanced solid tumor cancers.The Plandenied your request. The Plansaysthe test is not FDA approved for use in any cancer other than non-small cell lung cancer.The Planmust 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 wascorrect in denying the request to pay for the test. Our reviewer says that the test at issue in this case is not medically reasonable or necessary. Our physician reviewer found the enrollee is noted to have had stage IV GIST at the time of service. Testing related to GIST, and for which there were known therapies, would have been medically necessary and reasonable. Testing not related to GIST, or for which there were no known therapies, is not considered medically necessary or reasonable. Therefore, the provided panel testing, inclusive of tests not related to GIST and for which there are no known therapies, was 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 test have not been met.Therefore, we decided that the Plandoes not haveto pay forthe Guardant360 test provided to the enrollee on January 19, 2019.