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

We decided that the Plan does not have to pre-approve Nivolumab.
You asked the Plan to pre-approve Nivolumab. You say that this drug is medically necessary. The Plan denied your request. The Plan says Nivolumab is not medically necessary when cancer has progressed on Nivolumab treatment.
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 Nivolumab. Our reviewer says that the requested drug is not medically necessary and reasonable. Our physician reviewer found the enrollee has been diagnosed with metastatic gastric cancer. In this case, Nivolumab is not FDA-approved with progression while on treatment as is the case here. Furthermore, the use of Nivolumab is not supported by one of the major drug compendia or by clinical research that appears in a CMS-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 Nivolumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Nivolumab.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient mental health care provided on September 2, 2020.
You asked the Plan to waive the coinsurance for outpatient mental health care. You say that you disagree with the charges. The Plan denied your request. The Plan says the coinsurance you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% of the Medicare-allowed amount for each out of network Medicare-covered individual or group therapy visit.
The allowed amount of the claim is $124.21, resulting in a coinsurance obligation of $62.11 for an out of network outpatient mental health care visit. Outpatient mental health care visits fall within the outpatient mental health care 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 outpatient mental health care provided on September 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided
on November 16, 2020.
You asked the Plan to pay for the CGP testing. You say that you would like the Plan to reconsider their denial
of payment. The Plan denied your request. The Plan says the services are not covered as 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.
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have
to pay for the Comprehensive Genomic Profile (CGP) testing provided on November 16, 2020.
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 LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been 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 there is no documentation provided necessitating admission to an LTACH. The enrollee is receiving appropriate care at the present acute care facility. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient surgery provided on November 30, 2020.
You asked the Plan to waive the copayment for outpatient surgery. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment for each visit to an outpatient hospital facility.  You have been asked to pay a $350 copayment for outpatient surgery to remove polyps. Outpatient surgery falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers, 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 outpatient surgery provided on November 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited (problem focused) oral evaluation (D0140) provided on January 30, 2021.

You asked the Plan to pay for the limited evaluation. You say that you had this type of exam multiple times out of medical necessity; you had a problem with your tooth and were referred to two other providers for evaluation and treatment. The Plan denied your request. The Plan says only one limited oral evaluation may be covered in one plan year. You had a limited exam on January 7, 2021 that was paid for by the Plan. Therefore, payment cannot be made for the exam on the date in question.

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. The Plan can cover one limited exam to evaluate a problem per plan year.

Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation is requested in a frequency that is not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited (problem focused) oral evaluation (D0140) provided on January 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve physician services. You say that you would like to continue to see this doctor because you have been going there for years. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 physician services to be provided by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and the non-emergency transport (A0428) provided on October 26, 2020.
You asked the Plan to pay for the transportation services. You say that the provider received approval for this service from October 5, 2020, to November 4, 2020. You say that the service and diagnosis were not related to hospice. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.
The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on 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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and the non-emergency transport (A0428) provided on October 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar fusion surgery for the enrollee.

You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says the requested service is supported with no evidence of smoking.

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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no flexion, or extension x-rays showing spondylolisthesis instability. There is no nicotine test that shows that the enrollee has stopped smoking. Smoking is a contraindication to fusion.

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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar fusion surgery for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities described by current procedural terminology (CPT) code 97530 provided on June 17, 2020.
You asked the Plan to pay for CPT code 97530. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not supported in the records provided.
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 97530 is Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. We find that CPT code 97530 is not supported in the medical record. Specifically, the records indicate that the services were performed by an occupational therapist in a home health or hospice setting.
There is a more appropriate code for the services provided in this case. Based on this information, we decided that Medicare rules for coverage of CPT code 97530 have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities described by current procedural terminology (CPT) code 97530 provided on June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wireless capsule endoscopy (WCE).

You asked the Plan to pre-approve the WCE procedure. You say that it is felt that the WCE would be helpful in diagnosing the enrollee's condition. The Plan denied your request. The Plan says WCE is not medically indicated in this case.

The Plan follows Medicare rules. Medicare rules say that WCE is considered necessary when it is needed to locate suspected continuous intestinal blood loss. 

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 WCE procedure. Our reviewer says that the requested WCE is not shown to be medically reasonable and necessary. Our physician reviewer found the enrollee's records do not support that there is gross or occult ongoing blood loss. Her elevated ferritin level, normal mean corpuscular volume (MCV) results, and slowly decreasing hemoglobin levels suggest that the anemia is due to chronic disease, not from occult gastrointestinal bleeding. As such, the requested WCE is not warranted. 

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 WCE procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a wireless capsule endoscopy (WCE).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a psychotherapy visit provided on September 7, 2020.
You asked the Plan to waive the coinsurance for outpatient mental health visit. You say that you were told this provider was in-network. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% coinsurance for out-of-network outpatient mental health care. The allowed amount of this claim is $132.51, resulting in a coinsurance amount of $62.25 which is less than 50% coinsurance. You have been asked to pay less than 50% coinsurance for outpatient mental health visit. Outpatient mental health visit falls within the Outpatient Mental Health Care 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 a psychotherapy visit provided on September 7, 2020.
Your complaint regarding receiving inaccurate information about the network status of this provider is considered to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on July 28, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as 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 HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time.
The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on July 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ground mileage and a non-emergency ambulance transport to a medical doctor's office.
You asked the Plan to pre-approve the transportation services. You say that the enrollee is not legally able to drive to their appointment. You also say that the enrollee will need transportation to every appointment. The Plan denied your request. The Plan says the transportation to and from the requested destination are not covered.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 transportation services. Our reviewer says that the transportation services are not medically necessary. Our physician reviewer found the provided documentation does not indicate why other modes of transportation were not appropriate for the enrollee. The reviewer found that the provided documentation does not indicate that why ambulance transportation was medically necessary and reasonable for the enrollee as defined by Medicare rules. Therefore, the reviewer found that the requested transportation services are not medically reasonable or 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 transportation services have not been met. Therefore, we decided that the Plan does not have to pre-approve ground mileage and a non-emergency ambulance transport to a medical doctor's office.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the dental services (D0220, D0230, D0274, D1110) received November 10, 2020 from the out-of-network provider.
You asked the Plan to pay an additional amount for the dental services (D0220, D0230, D0274, D1110). You say that you were not told that the provider in this case was out-of-network. The Plan denied your request. The Plan says you can get care from an out-of-network dental provider, but you may pay more.
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 payment is in excess of those covered under this benefit. The Plan contract states that you can get care from an out-of-network dental provider, but you may pay more. The Plan paid 100% of the allowed cost for the requested services. You are responsible for the difference between the Plan's allowed amount and the amount charged by the out-of-network provider. Therefore, we decided that the Plan does not have to pay an additional amount for the dental services (D0220, D0230, D0274, D1110) received November 10, 2020 from the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
You asked the Plan to pre-approve a power seat elevation system. 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. Medicare rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300).