Persius/hicric huggingface dataset:
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs more therapy. The Plan denied your request. The Plan says that 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 above. 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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for abdominal pain due to diverticulosis. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 23, 2020.You asked the Plan to pay for the physician's services. 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 withthe Plan. The Plandid 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 October 23, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Superion interspinousspacer for the enrollee.You asked the Plan to pre-approvethese services. You say that these services are medically necessary.The Plan denied your request. The Plan says that this service is considered experimental and investigational.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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The device is experimental. More research is needed to show safety and efficacy. There is no spinal instability. Hardware not needed. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea Superion interspinous spacer for the enrollee
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveReblozyl for the enrollee.You asked the Plan to pre-approveReblozyl. You say that this is medically necessary.The Plan denied your request. The Plan says that the drug is not being prescribed for a medically-accepted indication.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 Reblozyl. Our reviewer says that Reblozyl is not medically reasonable and necessary for the enrollee in this case. Reblozyl is not FDA-approved for the enrollee's diagnosis. The use of Reblozyl is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is not listed as not indicated, not supported or not recommended in any of the compendia. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for coverage of Reblozyl.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Reblozyl have not been met.Therefore, we decided that the Plan does not have to pre-approveReblozyl for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe established patient office or other outpatient visit (99213) provided on October 9, 2020.You asked the Plan to waive the copayment forthe established patient office or other outpatient visit. You say that you believe your copayment should be reduced.The Plan denied your request. The Plan says the copayment has processed correctly for this case.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 $50 copayment for specialist visit. You have been asked to pay a $50 copayment for the established patient office or other outpatient visit. The service provided falls within the specialist visit 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 forthe established patient office or other outpatient visit (99213) provided on October 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist services rendered on October 8, 2020.You asked the Plan to waive the copayment forthese services. You say that the copayment should be waived due to COVID-19.The Plan denied your request. The Plan says the copayment was 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 $50 copayment for each Medicare-covered visit with a specialist. Review of the file shows that you received specialist services on October 8, 2020. The file shows that the services were not related to a COVID-19 infection. You have been asked to pay a $50 copayment for these services. These services fall within the Medicare-covered visit with a specialist 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 forthe specialist services rendered on October 8, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for esophagogastroduodenoscopy and colonoscopy provided on September 16, 2020.You asked the Plan to pay for the esophagogastroduodenoscopy and colonoscopy. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider,such as an urgent or emergency situation, has been documented. 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 servicesat 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 esophagogastroduodenoscopy and colonoscopy provided on September 16, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 12, 2020 by an out of network (OON) provider.

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 rendered by an out-of-network provider without 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on July 12, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forinteractive complexity (90785) provided on February 28, 2020.You asked the Plan to pay forthe interactive complexity. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says add-on codes may only be reported in conjunction with other codes, never alone.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, we have confirmed that code the interactive complexity is na add-on code and cannot be paid as billed as it has not been billed with a required primary procedure code. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay forinteractive complexity (90785) provided on February 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided by a participating provider on January 10, 2019, to June 18, 2019.You asked the Plan to waive the copayment for ambulance services. You say that you do not agree with these copayments. The Plan denied your request. The Plan says the correct copayment has been 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 the Plan clearly says that you must pay a $200 copayment for ambulance services/in-network/emergency ambulance. You have been asked to pay a $200 copayment for each ambulance trip. The total amount you are being asked to pay is $600 ($200 x 3 trips = $600). Ambulance services fall within the ambulance services/in-network/emergency ambulance 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 ambulance services provided by a participating provider on January 10, 2019, to June 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care (99222) provided on September 12, 2020.
You asked the Plan to pay for initial hospital care. You say that you provided medically necessary services in good faith. The Plan denied your request. The Plan says Medicare denies a claim if it is not received by the plan within twelve months or one calendar year from the date when the services were rendered. The claim was received on September 18, 2020. This is past the allowed twelve month timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for initial hospital care was not filed until September 18, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for initial hospital care (99222) provided on September 12, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveOpdivo.You asked the Plan to pre-approveOpdivo. You say that the enrollee's cancer has not responded to chemotherapy.The Plan denied your request. The Plan says that the use of Nivolumab monotherapy in neuroendocrine tumors is not Food and Drug Administration (FDA) approved, not identified as medically accepted in listed drug compendia, and not supported by evidence in published peer-reviewed medical literature.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 Opdivo. Our reviewer says that Opdivo is medically reasonable and necessary for the enrollee. Our physician reviewer found the use of Opdivo is supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our reviewer found that the use of Opdivo is not listed as not indicated,not supported or not recommended in any of the compendia. Our reviewer also found that the documentation does support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo have been met.Therefore, we decided that the Plan has to pre-approveOpdivo.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services (97814, 97813) provided on August 6,
2020 through August 20, 2020.
You asked the Plan to pay for the acupuncture services. You say that you would like reconsideration because
this is a covered benefit. The Plan denied your request. The Plan says this service was rendered by a noncovered
provider type.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to twelve sessions per ninety-day period, and no more
than twenty sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit.
As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, 
we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the record does 
not indicate that these services were rendered by a physician or under the supervision of a physician. Therefore, we 
decided that the Plan does not have to pay for acupuncture services (97814, 97813) provided on August 6, 2020
through August 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on August 13, 2020.You asked the Plan to waive the coinsurance for an injection. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct coinsurance has been 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 the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $91.29. The total amount you are being asked to pay is $18.26 ($91.29 x 20% = $18.26). An 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 an injection provided by a participating provider on August 13, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for nasopharyngoscopy with endoscope (CPT 92511) provided to the enrollee on February 5, 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 that Current Procedural Terminology (CPT) code 92511 (1 unit) remains 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 92511 is "nasopharyngoscopy with endoscope."

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 the services. Our reviewers says that the services at issue in this case were supported by the medical records. Our physician reviewer found on February 5, 2019, it is documented that diagnostic nasal endoscopy was performed to provide a more detailed examination of the nasal cavities. The nasal septum, sphenoethmoidal recess, inferior meatus, middle meatus, superior meatus and high nasal fossa were examined. The documentation in the case files supports that nasopharyngoscopy was performed on 2/5/2019.

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 services have been met. Therefore, we decided that the Plan has to pay for nasopharyngoscopy with endoscope (CPT 92511) provided to the enrollee on February 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (G0483) provided on August 13, 2020.
You asked the Plan to pay for the drug test. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the POS code billed does not match where the specimen was obtained.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code G0483 is not supported in the record. Specifically, this claim was billed with the laboratory place of service code, but the records indicate the specimen was obtained in an office setting. Based on this information, we decided that Medicare rules for coverage of the drug test have not been met. Therefore, we decided that the Plan does not have to pay for the drug test (G0483) provided on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 7, 2020 to August 24, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe rest home visits and advance care planning services (99327, 99336 and 99497) provided on August 7, 2020, through August 24, 2020.You say that you would like reconsideration because the provider rendered medically necessary services is good faith.The Plan denied your request. The Plan says these services were not urgent, emergent, referred by the member's PCP or approved in advance.Medicare rules say that plans can require enrollees to get care fromnetwork providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on August 7, 2020 to August 24, 2020 by an out of network (OON) provider.