Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740), core build up (D2950), a
prefabricated post and core in addition to a crown (D2954), an implant (D6010), and a partial upper denture
(D5213).

You asked the Plan to pre-approve the dental services. You say that your provider advised your tooth was too
weak for a crown and that an implant would be more appropriate. You say that your plan does not cover
implants. You say that you believe that your dental coverage should cover it. You say that The Plan denied
your request. The Plan says the requested services were not approved by your assigned dentist. The Plan says
that you need to use your assigned dentist to use your benefits. The Plan also says that implant is not listed as 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.

Though the Plan offers a dental benefit in excess of Medicare coverage and crowns are a covered service, the
services were not approved by your assigned dentist. The Evidence of Coverage clearly states that you will
need to choose a Dental Plan network dentist as your primary care dentist and visit that primary care dentist to
use your benefits. Additionally, the implant is not among those covered under this benefit. Therefore, we
decided that the Plan does not have to pre-approve a crown (D2740), core build up (D2950), a prefabricated
post and core in addition to a crown (D2954), an implant (D6010), and a partial upper denture (D5213).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation and report services coded 88321 provided on September 9, 2020.

You asked the Plan to pay for the consultation and report services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. 

In this case, the MUE for CPT code 88321 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the consultation and report services have not been met. Therefore, we decided that the Plan does not have to pay for the consultation and report services coded 88321 provided on September 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0425, A0428) provided on November 16, 2020.
You asked the Plan to pay for ambulance services. You say that the Plan is the enrollee's primary insurance, so this should be covered. The Plan denied your request. The Plan says no medical records have been received.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also 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 find that CPT codes A0425 and A0428 are not supported in the medical record. Specifically, no medical records have been submitted for these services. Without this information, the billed codes cannot be verified. Based on this information, we decided that Medicare rules for coverage of ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0425, A0428) provided on November 16, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided by an out-of-network provider on June 24, 2020.

You asked the Plan to pay for psychotherapy. You say that the services were rendered in accordance with the referring physician's orders. You say that the hospital should not be penalized for providing the appropriate medical treatment. The Plan denied your request. The Plan says a non-plan provider was not medically necessary.

The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. 

The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for psychotherapy provided by an out-of-network provider on June 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the control nasal hemorrhage services coded 30903 provided on June 26, 2020.

You asked the Plan to pay for the control nasal hemorrhage services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 30903 is control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method. 

We find that CPT code 30903 is not supported in the medical record. Specifically, the submitted medical records do not indicate that control nasal hemorrhage, anterior, complex any method was performed; therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the control nasal hemorrhage services have not been met. Therefore, we decided that the Plan does not have to pay for the control nasal hemorrhage services coded 30903 provided on June 26, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee. The Plan denied your request. The Plan says rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary a 70-year-old female who was admitted to the acute care hospital. While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Imfinzi for the enrollee.
You asked the Plan to pre-approve Imfinzi. You say that this drug is medically necessary. The Plan denied your
request. The Plan says Medicare coverage criteria are not 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 Imfinzi. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer
found in this case, the enrollee was treated with resection followed by two adjuvant chemotherapy regimens
prior to maintenance with Imfinzi. After 8 months, the enrollee had disease progression. The enrollee has had
12 months of treatment. The elements of the coverage rules are not satisfied. The literature does not support
that the requested drug is medically reasonable or necessary. The requested service cannot be recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to
pre-approve Imfinzi for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. The Plan says the enrollee can safely receive the services needed in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on October 29, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. 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 the services provided to you by an out-of-network provider on October 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda 100 mg/4 ml vial.

You asked the Plan to pre-approve Keytruda. You say that this drug is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says the requested drug is not necessary and reasonable 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 Keytruda. Our reviewer says that the
requested drug is not medically reasonable and necessary for the enrollee's condition. Our physician reviewer
found that in this case, the patient was on clinical trial of Keytruda for glioblastoma. Although this clinical trial
has ended, you wish to continue the enrollee on this drug. However, there is no compendia basis or literature
support for Keytruda for the enrollee's condition.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda 100 mg/4 ml vial.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics (A5501, A5513) provided on February 13, 2020.

You asked the Plan to pay for foot orthotics. You say that these items are supported by the records. The Plan denied your request. The Plan says there is not a valid order for these items.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid physician order for the supplies provided in this case. The physician order in the file is dated November 30, 2020, more than 10 months after the billed delivery date. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for foot orthotics (A5501, A5513) provided on February 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for inpatient hospital services provided from November 2, 2020, to November 18, 2020.

You asked the Plan to waive the coinsurance for inpatient hospital services. You say that the enrollee needed these services, and you would like this claim to be covered. The Plan denied your request. The Plan says the coinsurance amount that the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a 35% coinsurance for out-of-network Inpatient hospital care. The allowed amount of this claim totals $20,982.40, resulting in a total coinsurance amount of $7,343.80. 

The enrollee has been asked to pay a 35% coinsurance for inpatient hospital services. Inpatient hospital services falls within the Inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for inpatient hospital services provided from November 2, 2020, to November 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient care is medically
necessary. The Plan denied your request. The Plan says the inpatient hospital stay following surgery is not
medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found you are a 68-year-old female with left shoulder pain related to osteoarthritis who
presented to the hospital for an elective total shoulder arthroplasty. Past medical history significant for diabetes
mellitus. Your medical history is not significant for being a high-risk patient and the procedure is low risk,
approved for ambulatory surgery. There was no suggestion from the notes that you would require hospital
services that would be expected to cross two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that the inpatient stay is medically necessary. The Plan denied your request. The Plan says inpatient stay after the approved surgery is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is an 81-year-old female with shoulder pain with right rotator cuff Arthropathy. She is scheduled for right reverse total shoulder arthroplasty. Her provider has requested an inpatient admission for the procedure. The review has determined that the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of torus mandibularis (D7473 x 2) provided on September 26, 2020.

You asked the Plan to pay for the dental service. You say that although the surgery was done by a dentist, it needs to be considered medical. You also say that this should be covered by your medical plan. The Plan denied your request. The Plan says the service you received is considered dental in nature. The Plan says that removal of torus mandibularis is not listed as a covered service. The Plan also says that any services no listed 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 removal of torus mandibularis (D7473 x 2) provided on September 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the duplex scan of lower extremity arteries (93925) and duplex scan of extremity veins (93971).

You asked the Plan to pre-approve the duplex scan of lower extremity arteries and duplex scan of extremity veins. You say that the requested scans are medically necessary. The Plan denied your request. The Plan says the requested services do not meet the Medicare rules for coverage.

The Plan follows Medicare rules. Medicare rules say that an ABI should be abnormal before additional studies are ordered.

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 duplex scan of lower extremity arteries and duplex scan of extremity veins. Our reviewer says that the requested services are not medically necessary and reasonable.

Our physician reviewer found the patient is a 79-year-old male with right leg pain. A request for a complete bilateral duplex scan of veins and arteries was made. Peripheral pulses were normal and ABIs were ordered but not resulted or provided in the records for review. Without a significantly abnormal ABI this request for bilateral leg Duplex scan will be considered not medically necessary. Also, there was no left-sided evidence of disease on exam or reported complaints.

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 duplex scan of lower extremity arteries and duplex scan of extremity veins have not been met. Therefore, we decided that the Plan does not have to pre-approve the duplex scan of lower extremity arteries (93925) and duplex scan of extremity veins (93971).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya- Injection.

You asked the Plan to pre-approve Ilumya- Injection, Tildrakizumab, 1 mg (J3245). You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says the health plan states the enrollee has not first tried and had a contraindication or intolerance to Enbrel, Humira, or Skyrizi.

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 Ilumya- Injection, Tildrakizumab, 1 mg (J3245). Our reviewer says that the drug is not reasonable and medically necessary. Our physician reviewer found the case file does not contain documentation of trial and failure of Enbrel, Humira, or Skyrizi. The documentation does not support that Enbrel, Humira, or Skyrizi would likely be less effective, and/or would likely have adverse effects for the enrollee 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 Ilumya- Injection, Tildrakizumab, 1 mg (J3245) have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya- Injection.