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

We decided that the Plan does not have to pre-approve Imfinzi (durvalumab). You asked the Plan to pre-approve Imfinzi. The Plan denied your request. The Plan says this is 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 Imfinzi. Our reviewer says that Imfinzi (durvalumab) is not medically reasonable and necessary in this case. Our physician reviewer found that durvalumab is FDA approved for the treatment of unresectable stage III non-small cell lung cancer in adults, whose disease has not progressed following concurrent platinum-based chemotherapy and radiation therapy. It carries no off-label indications for non-small lung cancer, and use in this situation is not supported by the medical literature. The enrollee did not receive radiation therapy and appeared to take a more palliative than curative approach. Durvalumab in this situation is not considered a standard 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 Imfinzi have not been met. Therefore, we decided that the Plan does not have to pre-approve Imfinzi (durvalumab).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (G0249) provided on January 8, 2020, and January 15, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the frequency limit has been exceeded.The Plan must follow Medicare rules. Medicare rules say that code G0249 is payable once every 25 days. We looked at the file and Medicare rules. The records show that code G0249 was paid on for date of service January 2, 2020. The requested services were provided within 25 days of the paid claim, which means that the benefit limit has been exceeded. 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 services (G0249) provided on January 8, 2020, and January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased on March 7, 2019 from an out-of-network provider.
You asked the Plan to pay for hearing aids. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says you do not have out-of-network benefits.
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. Review of the file show that you purchased hearing aids on March 7, 2019 from an out-of-network provider. Your EOC states, hearing aids must be ordered directly from an in-network supplemental hearing provider. 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 hearing aids purchased on March 7, 2019 from an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two crowns (D2740 x2) and two core buildups, including
any pins when required (D2950 x2) provided on February 5, 2019.
You asked the Plan to pay for the crowns and core buildups. You say that these services were medically
necessary because you were having trouble chewing your food. The Plan denied your request. The Plan says
these services are not covered benefits under your dental 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, 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 two
crowns (D2740 x2) and two core buildups, including any pins when required (D2950 x2) provided on February
5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0482)
provided to the enrollee on December 12, 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 according to the claims data available at the time of the review, the plan was unable to discover
any evidence of an established relationship between the member and the ordering physician.
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:
CPT 80307:
Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument
chemistry analyzers (e.g., utilizing immunoassay [e.g., EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]),
chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (e.g.,
DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation
when performed, per date of service
HCPCS G0482:
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; 15-21 drug class(es), including
metabolite(s) if performed . 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 documentation submitted
was reviewed. The documentation does not support that the ordering physician is the treating physician, as per
Medicare guidelines; laboratory testing must be ordered by the treating physician.
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 (CPT 80307 and HCPCS G0482) provided to the enrollee on December
12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided by an opt-out provider on
February 7, 2020.
You asked the Plan to pay for the office visit. You say that you would like reconsideration because these
services have been covered in the past. The Plan denied your request. The Plan says you received services from
a non-Medicare certified provider and are responsible for the entire cost of the services.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This
provider has opted out of the Medicare program. The record indicates that this provider opted out of Medicare
on January 1, 2019. Therefore, we decided that the Plan does not have to pay for an office visit (99214)
provided by an opt-out provider on February 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from October 4, 2019 through October 8, 2019.You asked the Plan to waive the copayment for the inpatient stay. You say that your maximum out-of-pocket for 2019 was met. You say that you overpaid.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $265 copayment per day, per stay for days 1-9.You have been asked to pay $402.94, which is less than the standard copayment for the inpatient stay because you met your maximum out-of-pocket. The inpatient stay falls within the "Inpatient hospital care" benefit category. The records show that your maximum out-of-pocket had not been met prior to the inpatient stay. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for the inpatient stay provided from October 4, 2019 through October 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria for transfer to an LTACH
are not met.
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 according to the records provided, current clinical status required ongoing ventilation
weaning, hemodialysis, and monitoring which warrants an acute care facility stay. However, you do not require
any services available at the LTACH that are not already available at the current acute care facility. There are
no services available at the proposed LTACH that the enrollee requires that are not available and covered at the
current acute care facility. Therefore, based on the provided documentation, the requested LTACH services
will be considered not medically necessary 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-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 4, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for physician services. You say that you switched your primary care physician. You
say that you no longer need a referral to see your new primary care physician. The Plan denied your request.
The Plan says the rendering physician is out-of-network. The Plan says that 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 physician services provided on February 4, 2020
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride provided on March 16, 2020. You asked the Plan to pay for the topical application of fluoride. You say that the pamphlet you received for the comprehensive plan says that fluoride treatments are a covered benefit. The Plan denied your request. The Plan says your plan does not cover this procedure. 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 topical application of fluoride provided on March 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Austedo (J8499).
You asked the Plan to pre-approve Austedo. You say that it is medically necessary that the enrollee starts Austedo to achieve longer relief from his tardive dyskinesia. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition 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-approve Austedo (J8499).
Benefits for Austedo 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 the office visit (99212) provided on November 21, 2019. You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says separate payment is not allowed for Evaluation and Management services reported during the postoperative period with modifier 24 without sufficient indication that the visit is unrelated to the surgery. The Plan must follow Medicare rules. Medicare rules say that carriers do not allow separate payment for postoperative visits or services within 10 days of the surgery that are related to recovery from the procedure. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Specifically, the record indicates that the surgery has a global surgery indicator of 010. This service was rendered within the 10 day postoperative period and there is no indication that this service was unrelated to the surgery. Therefore, we decided that the Plan does not have to pay for the office visit (99212) provided on November 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve semi-electric hospital bed with mattress (E0260). You asked the Plan to pre-approve semi-electric hospital bed with mattress. You say that you are requesting an appeal because you need the hospital bed due to an upcoming surgery. The Plan denied your request. The Plan says the enrollee does not meet the medically necessary criteria for the semi-electric hospital bed.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requires frequent changes in body position and/or has an immediate need for a change in body position.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 semi-electric hospital bed with mattress. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's condition does not require positioning of the body in ways not feasible in an ordinary bed. The enrollee does not require frequent or immediate needs for changes in body position. The enrollee's condition does not need special attachments that cannot be fixed and used on an ordinary bed. A semi-electric hospital bed is not medically 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 semi-electric hospital bed with mattress have not been met.Therefore, we decided that the Plan does not have to pre-approve semi-electric hospital bed with mattress (E0260).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF services after June 24, 2020.
You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says based on
Medicare guidelines the enrollee does not meet the requirements for continuation of SNF coverage.
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 the SNF services. Our reviewer says
that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing
perspective, the enrollee received oral medications. The enrollee had stable vital signs. Regarding rehabilitation
services, the enrollee received physical therapy (PT), speech therapy (ST) and occupational therapy (OT) in the
SNF. By the dates in question, the enrollee was at a supervision to contact guard assist level with functional
mobility including gait to 225 feet with a rollator walker. The enrollee required varying assist with activities of
daily living (ADL). He tolerated a regular diet. Our physician reviewer found that there are no identifiable
skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not
require skilled nursing or therapy services on a daily basis. As a practical matter, the enrollee does not meet
severity of illness or intensity of service criteria on 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 the SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve continuation of SNF services after June 24, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the pouchoscopy provided on March 4, 2020.
You asked the Plan to waive the copayment for the pouchoscopy. You say that this is the same procedure done for a colonoscopy or sigmoidoscopy. You say that this is not a surgery and shouldn't be classified as such. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $225 for each in-network, Medicare-covered outpatient hospital facility visit. You have been asked to pay a $225 copayment for the pouchoscopy. The pouchoscopy falls within the "Outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The pouchoscopy is considered a surgical procedure. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the pouchoscopy provided on March 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided on December 19, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for radiology services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says the referring provider is out-of-network.
The Plan says that 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 radiology services provided on December 19,
2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the sales tax for the rental on October 30, 2019. 
 
You asked the Plan to reimburse you for the sales tax. You say that you needed the lift to be able to get released from the hospital. The Plan denied your request. The Plan says they will reimburse you the Medicare allowable but you are responsible for 20% coinsurance, fees above the Medicare allowable, and the sales tax. 
 
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 Durable Medical Equipment and related supplies.  
 
You have been asked to pay the sales tax and 20% coinsurance for the Patient Lift. The Patient Lift falls within the Durable Medical Equipment and related supplies 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. The Plan has reimbursed you the Medicare allowable. Sales tax is not separately reimbursable. Therefore, we decided that the Plan does not have to reimburse you for the sales tax for the rental on October 30, 2019.