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

We decided that the Plan has to pre-approve Akynzeo for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this drug is supported when used to prevent nausea and vomiting caused by chemotherapy.
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 the drug. Our reviewer says that the requested drug is medically reasonable and necessary. Our physician reviewer found Akynzeo is indicated for the prevention of emesis in patients receiving high or moderately emetogenic chemotherapy. This enrollee is planning carboplatin and etoposide. The dose of carboplatin in this regimen meets criteria for high emetogenic potential, therefore, Akynzeo would be indicated. The service is reasonable and medically 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 the drug have been met. Therefore, we decided that the Plan has to pre-approve Akynzeo for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing.
You asked the Plan to pre-approve genetic testing. The Plan denied your request. The Plan says there is no
information that indicates breast, ovarian, or GI malignancy in the enrollee.
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 genetic testing. Our physician reviewer
found that there is no evidence of a personnel history of cancer. There is no evidence of breast or ovarian
cancers in younger-aged relatives. There is no documentation of a plan to obtain genetic testing, and
documentation of why such testing would be needed. The documentation does not support that the requested
testing is medically necessary or reasonable to diagnoses, treat or otherwise manage your health.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not
have to pre-approve genetic testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crown - porcelain/ceramic (D2740) and core buildup, including any pins when required (D2950), for the enrollee. 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied your request. The Plan says the services are not necessary. 
 
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. 
 
There is insufficient deterioration or breakdown to approve requested procedures. The existing restorations are minimal and there is sufficient tooth structure for alternative therapy. Therefore, we decided that the Plan does not have to pre-approve crown - porcelain/ceramic (D2740) and core buildup, including any pins when required (D2950), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 18, 2020 by an out of network (OON) provider.You asked the Plan to pay for the extremity study (93971). You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says non-urgent services should be from network providers who are contracted with the member's health plan and listed in the Provider Directory.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 the medical services provided on February 18, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a E2300 power seat elevation system for the enrollee's power wheelchair.
You asked the Plan to pre-approve an E2300 power seat elevation system for the enrollee. You say that this seat elevation system is medically necessary. The Plan denied your request. The Plan says neither Medicare nor the Plan covers the E2300 seat elevation system.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules specifically exclude an E2300 power seat elevation system from coverage. Therefore, we decided that the Plan does not have to pre-approve a E2300 power seat elevation system for the enrollee's power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injection provided on April 12, 2017.
You asked the Plan to waive the coinsurance for the Part B injection. You say that the Plan should process and pay this claim accordingly. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 20% coinsurance for each Medicare-covered Part B drug. You have been asked to pay $645.67 which is 20% of the allowed amount for the Part B injection. The allowed amount is $3,228.34. ($3,228.34 x 20% = $645.67). The Part B injection falls within the "Medicare Part B prescription drugs" 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 coinsurance for the Part B injection provided on April 12, 2017.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for laboratory services provided on March 27, 2020.
You asked the Plan to waive the deductible for laboratory services. You say that you thought that the laboratory services would be in-network. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible for out-of-network outpatient diagnostic tests and therapeutic services and supplies. You received laboratory services on March 27, 2020 from an out-of-network provider. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The record shows that you had paid $0 toward the $500 deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of $59.37. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for out-of-network outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time laboratory services was received on March 27, 2020. Therefore, we decided that the Plan does not have to waive the deductible for laboratory services provided on March 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services (97012, 97032, 97530)
provided from September 12, 2019, to October 28, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were
billed without the appropriate modifier.
The Plan must follow Medicare rules. Medicare rules say that claims containing any of the "always therapy"
codes must have one of the therapy modifiers appended (GN, GO, GP).
We looked at the file and Medicare rules. The services in question are considered "always therapy" services.
These services require the use of one of the modifiers mentioned above. The services were not billed with one
of the appropriate modifiers. Based on this information, we decided that Medicare rules for coverage of the
services have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy
services (97012, 97032, 97530) provided from September 12, 2019, to October 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on January 22, 2020. You asked the Plan to pay for the problem focused limited oral evaluation. You say that you saw this provider in 2020 when you had new benefits. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan. 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, problem focused limited oral evaluation is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation on January 17, 2020 and your problem focused limited oral evaluation benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on January 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of atezolizumab in a chemotherapy regimen.
You asked the Plan to pre-approve atezolizumab. You say that you are appealing with medical records. The
Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is
not supported for the enrollee's type of cancer.
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 atezolizumab. Our reviewer says that
the enrollee does not meet the Medicare criteria for the use of atezolizumab in the requested chemotherapy
regimen. Our physician reviewer found the use of atezolizumab (along with the approved
carboplatin/etoposide) is not approved by the Food & Drug Administration (FDA) for the enrollee's diagnosis.
The enrollee has a large cell neuroendocrine cancer of the uterus, this drug is FDA-approved for extensive
stage small cell cancer. The use of this drug in this context is not supported by major drug compendia or by
clinical research that appears in a Medicare-approved medical journal.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of atezolizumab have not been met. Therefore, we decided that the Plan does not
have to pre-approve use of atezolizumab in a chemotherapy regimen.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes (CPT Code 99239) provided to the enrollee on November 1, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Review of the file show that 99239 was previously reported and processed for date of service November 1, 2019. Services were reported by the same physician on both the denied claim and the referring/processed claim. Therefore, we decided that the Plan
does not have to pay for hospital discharge day management; more than 30 minutes (CPT Code 99239) provided to the enrollee on November 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the wig purchased on July 12, 2019.
You asked the Plan to reimburse you for the wig. You say that because of your medical condition you need a
wig. The Plan denied your request. The Plan says wigs are not covered by Medicare or the Plan.
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are
ordered by a physician. The Plan follows these same rules.
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would
provide coverage for a wig. Therefore, we decided that the Plan does not have to reimburse you for the wig
purchased on July 12, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on October 17, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 skilled nursing services provided on October 17, 2019 by an out of network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on December 9, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of the denied codes is: HCPCS G0483: Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. CPT 80177: Levetiracetam CPT 80201: Topiramate CPT 80162: Digoxin CPT 80159: Clozapin CPT 80173: Haloperidol CPT 80157: Carbamazepine We asked our coding 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 the services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found the specimen type collected in the patient's medical record was urine. A blood specimen collected by venipuncture is required for 80177, 80201, 80162, 80159, 80173, and 80157. The collection of the required specimen cannot be validated, therefore, these services cannot be verified. The medical records provided do not include documentation in the form of a physician lab order stating the exact tests to be performed. Also, this information is not documented anywhere else in the enrollee's medical record, therefore this service cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on December 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services from June 22, 2020 onward.You asked the Plan to pre-approve these services. You say that the enrollee is not safe to discharge.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 was admitted to the hospital on June 19, 2020 with recurrent major depressive disorder and to rule out dementia. He presented with depression and had attempted suicide. The records show that he is not showing any dangerousness to self or others and no auditory or visual hallucinations. He is described as being calm. He does not have suicidal or homicidal thoughts or abnormal behaviors. It does not appear that active treatment is taking place beyond the dates in question. The continued services are therefore not reasonable or medically 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services from June 22, 2020 onward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on March 5, 2020 by an out of network (OON) provider.You asked the Plan to pay for outpatient services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also 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 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 outpatient services provided on March 5, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection gastrointestinal (GI) panel rendered on December 14, 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 were not medically necessary.
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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of unspecified diarrhea. The submitted documentation includes a laboratory order and test results. The records do not include a provider progress note, physical exam, documentation of medical history, previous stool tests and cultures, or detailed assessment and plan. Without the support of the documentation, the testing was not medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the infectious agent detection gastrointestinal (GI) panel rendered on December 14, 2019.
The Local Coverage Article (LCA) referenced by the Plan is not binding for Part B Medicare for the state where the testing was performed and was not used in the Maximus determination.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).You asked the Plan to pre-approve the requested CGM. You say that you'll be able to monitor your blood sugar much better.The Plan denied your request. The Plan says the device is not covered if you are not on insulin.The Plan follows Medicare rules. Medicare rules say that continuous glucose monitors are only covered under certain medical indications.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 requested CGM. Our physician reviewer found that the records do not support you use insulin with 3 or more daily injections. Without the support of the documentation, guidelines are not supported. Therefore, the CGM is not reasonable and 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 the requested CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).