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

We decided that the Plan does not have to pre-approve Tecentriq (J9022).
You asked the Plan to pre-approve the Tecentriq. You say that the Tecentriq is medically necessary for
treatment of the member's condition. The Plan denied your request. The Plan says Medicare guidelines do not
show this combination of treatment is supported in the member's type of cancer.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
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 the Tecentriq. Our reviewer says that
review of compendia does not support the use of Tecentriq for the enrollee's diagnosis. Our physician reviewer
found without the literature support, medical necessity cannot be determined.
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 Tecentriq have not been met. Therefore, we decided that the Plan does not
have to pre-approve Tecentriq (J9022).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on October 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for lab work provided on October 18, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for ECG interpretation (93010) provided October 5, 2019.
You asked the Plan to pay for the ECG interpretation. You say that the services were medically necessary. The Plan denied your request. The Plan says the services share a bundled relationship and cannot be billed as separate line items without modifiers.
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 93010 shares a bundled relationship with code 36556 and cannot be paid as billed. 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 for ECG interpretation (93010) provided October 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November
18, 2019.
You asked the Plan to pay for the dental service. You say that you have not been seen in 18 months. You say
that the office advised that the service would be covered. You also say that you should not be liable for the visit
as you were never told there would be a cost. The Plan denied your request. The Plan says limited oral
evaluations are covered once per patient, per provider. The Plan also says that the frequency limit has been
exceeded.
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 and limited oral evaluations are listed
as a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for this
service on March 3, 2017 that you received from the same provider. Therefore, we decided that the Plan does
not have to pay for the limited oral evaluation (D0140) provided on November 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvere vision of previous bariatric surgery.You asked the Plan to pre-approve the bariatric surgery revision. You say that the enrollee believes that this surgery is necessary for her to lose weight.The Plan denied your request. The Plan says the enrollee does not meet the criteria as she has already failed prior surgery and has not demonstrated adequate lifestyle changes and compliance to support that this surgery would be more effective than the last.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 bariatric surgery revision. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 47-year-old woman with a diagnosis of Morbid (severe) obesity due to excess calories. The enrollee previously underwent laparoscopic Roux-en-Y gastric bypass on 2/1/12. The 8/6/19 physician office visit notes that "it is questionable if it would be beneficial to her to undergo revision of surgery, without addressing her behavioral problems." The 9/10/19 Psychosocial Assessment notes that the clinician's impressions about likelihood of the enrollee's adhering to the Weight Center treatment was poor. The 12/26/19 Weight Center Psychology note documents that the enrollee had not in fact been making any changes, and was very focused on revision surgery, and appeared to be only interested in behavior change vis-a-vis this being what was mandated by her team in order to move forward with surgery. The documentation in the case file does not support that revision bariatric surgery is medically reasonable and necessary for the enrollee in this case. She has previously failed bariatric surgery, and has not adapted sufficientlifestyle changes and appropriate compliance to support that the requested surgery would likely benefit the enrollee in a sustained fashion.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 bariatric surgery revision have not been met.Therefore, we decided that the Plan does not have to pre-approverevision of previous bariatric surgery.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided on September 29, 2019.You asked the Plan to pay for the ambulance service. You say that the enrollee is non-ambulatory.The Plan denied your request. The Plan says the enrollee could have been safely transported by another type of vehicle.Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. We looked at the file and Medicare rules. The enrollee was not bed-confined. Based on this information, we decided that Medicare rules for coverage of the ambulance service have not been met.Therefore, we decided that the Plan does not have to pay for services provided on September 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for unlisted dialysis procedure, inpatient or outpatient (CPT Code 90999) from May 1, 2019 through June 12, 2019.
You asked the Plan to waive the copayment for the services. You say that you did not have dialysis after April 22, 2019. The Plan denied your request. The Plan says the records show that you did have dialysis after April 22, 2019.
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 medical records show that you actually did have treatments on April 26, 2019, May 1, 8, 15, 22, 29, 2019, June 5 and 12, 2019. You are responsible for the cost-share for dialysis. 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 unlisted dialysis procedure, inpatient or outpatient (CPT Code 90999) from May 1, 2019 through June 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that you needed to use this provider because the covered providers did not have appointments available until 2020. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and 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 the medical services provided on October 14, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says care can be received in another setting.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's medical conditions appear stable. There are no wound care needs. There are no unaddressed medical issues. She does not require medical oversight of her condition at an acute hospital level of care. She is ambulating greater than household distances and is performing essential activities of daily living without hands-on assistance and does not require an intensive rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. The member's care can be appropriately provided at an SNF level.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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on October 31, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you shouldn't owe for a follow up visit. You say that the copayment should be reversed. 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 $35 for each Medicare-covered specialist office visit. You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. There is no provision in the contract which indicates a copayment would be waived for services performed as a follow-up. 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 office visit provided on October 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a vaginal hysterectomy provided from January 8, 2019 to January 10, 2019.
You asked the Plan to waive the copayment for a vaginal hysterectomy. You say that you were admitted inpatient and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The medical records show that you had a vaginal hysterectomy during an outpatient hospital stay from January 8, 2019 to January 10, 2019. Therefore, you are responsible to pay the $75 copayment. You have been asked to pay a $75 copayment for a vaginal hysterectomy. A vaginal hysterectomy 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 a vaginal hysterectomy provided from January 8, 2019 to January 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for Inpatient Mental Health Services provided November 4 to November 8, 2019.
You asked the Plan to pay for the Inpatient Mental Health Services. You say that the services were medically necessary. The Plan denied your request. The Plan says rules for coverage were not met.
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 pay for the Inpatient Mental Health Services. Our reviewer says that inpatient level mental health services were not medically necessary. Our physician reviewer found the enrollee did not appear to require inpatient mental health treatment as he was not a danger to himself or others and was cooperative and compliant. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of his diagnosis.
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 Inpatient Mental Health Services have not been met. Therefore, we decided that the Plan does not have to pay for Inpatient Mental Health Services provided November 4 to November 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on August 30, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at
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 the medical services provided to the enrollee by an out-of-network provider
on August 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crutch substitute (E0118).
You asked the Plan to pre-approve the crutch substitute. You say that the member is unable to ambulate and needs a scooter for activities of daily living. The Plan denied your request. The Plan says there is insufficient published clinical literature demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for crutch substitutes.
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 crutch substitute. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not indicate contraindication to standard wheelchair use. 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 crutch substitute have not been met. Therefore, we decided that the Plan does not have to pre-approve a crutch substitute (E0118).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on April 17, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on April 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (CPT Code 99309) provided
to the enrollee on August 8, 2019.
You asked the Plan to pay for the services. You say that this service was provided by two different providers.
The Plan denied your request. The Plan says this claim was processed correctly per how the provider billed the
services.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the services have not been met. Only one evaluation management
procedure is allowed per specialty per day and this 99309 has been billed on history claim 02036516500. The
provider specialty on both claims is Internal Medicine. Therefore, we decided that the Plan does not have to
pay for subsequent nursing facility care (CPT Code 99309) provided to the enrollee on August 8, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the lower left extremity (73718).
You asked the Plan to pre-approve MRI. You say that the MRI is needed. The Plan denied your request. The Plan says that coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the MRI is medically necessary. Our physician reviewer found MRI without contrast can be performed if physical exam and plain X-ray fails to establish a definitive diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI have been met. Therefore, we decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the lower left extremity (73718).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 6, 2019 by an out of network (OON) provider.
You asked the Plan to pay for laboratory testing. You say that this testing was ordered by an in-network provider to assist in determining optimal treatment options for the enrollee. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on September 6, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 5, 2019 by an out of network (OON) provider.You asked the Plan to pay for esophagogastroduodenoscopy (EGD). You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and 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 the medical services provided on March 5, 2019 by an out of network (OON) provider.