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

We decided that the Plan has to pre-approve liver ablation.
You asked the Plan to pre-approve liver ablation. The Plan denied your request. The Plan says that this is not
medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically 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 liver ablation. Our reviewer says that
the requested liver ablation is considered medically reasonable and necessary in this case. Our physician
reviewer found that per NCCN guidelines for inoperable disease, ablation is supported, including microwave.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of liver ablation have been met. Therefore, we decided that the Plan has to preapprove
liver ablation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on August 23, 2019 through November 4, 2019.
You asked the Plan to pay for the home infusion therapy. You say that this infusion code is not a durable medical equipment cod and was not delivered to the member's home. The Plan denied your request. The Plan says S codes are not payable by Original Medicare.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on August 23, 2019 through November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on January 12, 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 prior authorization was not 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 outpatient services provided on January 12, 2020
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that you need occupational therapy. The Plan denied your request. The Plan says medically necessary care is available in-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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on January 30, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not
payable by the Plan while enrolled in hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the services provided on January 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on October 8, 2019.
You asked the Plan to waive the copayment for the laboratory work. You say that you should not be responsible for the copayment because the laboratory work was a part of your annual physical. 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 a $20 copayment per visit for laboratory tests, non-radiological tests, flat film x-rays, and ultrasounds. You have been asked to pay a $20 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and 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. Therefore, we decided that the Plan does not have to waive the copayment for the laboratory work provided on October 8, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve use of PuraPly AM wound care matrix.
You asked the Plan to pre-approve PuraPly. You say that you doctor wants to use PuraPly for follow-up care
after surgery. The Plan denied your request. The Plan says that the denial of authorization for these supplies is
correct, because there is insufficient quantity of published, peer-reviewed, human clinical data to evaluate
PuraPly for treatment of wounds.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically 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 PuraPly. Our reviewer says that the
requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found you have failed a long course of conventional therapy and this is not being used as a primary or
even secondary line of therapy. It is medically reasonable to try this for wound management. You also have
upcoming procedures that are necessary but are being delayed due to this poorly healing wound, which has
caused long-term morbidity.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of PuraPly have been met. Therefore, we decided that the Plan has to pre-approve
use of PuraPly AM wound care matrix.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on February 28, 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 denied services were 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 the denied codes is:
CPT 87086:
Culture, bacterial; quantitative colony count, urine.
CPT 87088:
Culture, bacterial; with isolation and presumptive identification of each isolate, urine.
CPT 87186:
Susceptibility studies, antimicrobial agent; microdilution or agar dilution (minimum inhibitory concentration
[MIC] or breakpoint), each multi-antimicrobial, per plate
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 reviewer says that the
services at issue in this case were not supported by the medical records. Our physician reviewer found the
medical records provided does not include a valid lab order/requisition signed by the ordering physician,
therefore these services cannot be verified.
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 not been met. Therefore, we decided that the Plan does not
have to pay for lab services provided to the enrollee on February 28, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Onpattro (patisiran) injections.
You asked the Plan to pre-approve the Onpattro injections. You say that this is medically necessary. The Plan denied your request. The Plan says that this drug is not covered under Medicare Part B.
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 Onpattro injections. Our reviewer says that the requested medication is considered medically reasonable and necessary. Our physician reviewer found in this case, the records provided for review support that the patient has a diagnosis of hereditary ATTR polyneuropathy. The diagnosis was confirmed via genetic testing (and via cardiac muscle biopsy). The requested drug is FDA approved for use in this specific condition. In that regard, it can be said that this drug (Onpattro) would be reasonable and necessary for the patient. 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 Onpattro injections have been met. Therefore, we decided that the Plan has to pre-approve Onpattro (patisiran) injections.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from February 24, 2020 through February 28, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on February 24, 2020 and discharged on February 28, 2020. You were asked to pay a $265 copayment per day from February 24, 2020 through February 27, 2020, days 1-4 of your inpatient hospital care. You were discharged on February 28, 2020 and there was no copayment charge for the day of discharge. Per your contract there is a $265 copayment per day required for days 1-7. 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 inpatient hospital care from February 24, 2020 through February 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the office visit services. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says that there are equally qualified in-network providers available to you that can provide the care you are requesting.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office visit services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for observation care provided on April 10, 2020 by an in-network provider.
You asked the Plan to waive the copayment for the observation care. You say that you feel you should not be responsible for the copayment for the services because you had to go back to the hospital. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received observation care provided on April 10, 2020 by an in-network provider. You are asked to pay a $350 copayment for the observation care. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for observation care provided on April 10, 2020 by an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on
March 25, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be
responsible for the copayment. 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 a $45
copayment for each specialist office visit for Medicare-covered services.
You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner services, including doctor's office 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 for the specialist office visit provided on March 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve a home ventilator, any type, used with non-invasive interface (E0466). You say that the enrollee meets criteria for a home ventilator. The Plan denied your request. The Plan says the medical records did not support the medical necessity required to approve the request for a home ventilator with non-invasive interfaces.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 a home ventilator, any type, used with non-invasive interface (E0466). Our reviewer says that the home ventilator is not medically necessary. Our physician reviewer found coverage criteria for a home ventilator are not met. This enrollee has severe COPD with chronic hypercapnic respiratory failure. The enrollee may qualify for, and benefit from, nightly respiratory support with BiPAP. Certain BiPAP devices are capable of providing the AVAPS-AE mode of ventilation that is ordered. Medicare does not cover a home ventilator when used as a BiPAP device. There is no documented failure of BiPAP. A home ventilator is not medically necessary, and the denial is upheld. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator, any type, used with non-invasive interface (E0466) have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Prolia injections provided on March
25, 2019 and October 8, 2019.
You asked the Plan to waive the coinsurance for the Prolia injections. You say that this service was previously
paid under the Part D plan and you say the member should not be responsible for this amount. 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). The enrollee's contract with the Plan clearly says that enrollees
must pay 20% coinsurance for in-network Medicare Part B covered drugs.
The enrollee has been asked to pay $476.14 for the Prolia injections. The Prolia injections fall within the
"Medicare Part B prescription drugs" benefit category. See chart below.
Date of Service Service Allowed Amount Coinsurance Member Liability
March 25. 2019 Prolia injection $1,730.34 20% $234.08
October 8, 2019 Prolia injection $1,210.33 20% $242.06
Total $476.14
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 the Prolia injections provided on March 25,
2019 and October 8, 2019.
Our decision is only about the 2019 services. If you have any questions about prior years billing, please contact
the plan directly
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a decompression spacer procedure for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation that the enrollee is enrolled in an approved clinical study.
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 the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this spacer is experimental, and more research is needed. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a decompression spacer procedure for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient mental health facility for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical information provided did not support the inpatient level of care.
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 the admission. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment facility beyond the date in question. The enrollee could be treated in a lesser restrictive setting, as he was not showing any suicidial or homicidal ideation, auditory or visual hallucinations, delusions, and was not showing any behaviors or aggression. The enrollee was cooperative and compliant, while not showing any acute threats to safety.
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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to an inpatient mental health facility for the enrollee.