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

We decided that the Plan does not have to pre-approve Xtandi.

You asked the Plan to pre-approve Xtandi. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.

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 Xtandi.

Benefits for Xtandi 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 15, 2020, to November 6, 2020.

You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says inpatient care was not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee is a 67-year-old male who was admitted to the hospital for a non-emergent surgical PEG placement. Upon immediate assessment prior to the procedure, the enrollee's vitals were stable, his anemia was stable, and there was no other acute care needs to justify inpatient treatment that would have been expected to cross 2 midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 15, 2020, to November 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemotherapy services provided on September 2, 2020 and September 23, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the chemotherapy services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the chemotherapy services provided on September 2, 2020 and September 23, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of an auricular percutaneous electrical nerve stimulator.

You asked the Plan to pre-approve auricular nerve stimulator. You say that the enrollee is likely to obtain significant therapeutic benefit from this device. The Plan denied your request. The Plan says this device is not medically necessary and is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that use of an auricular electro-acupuncture device is not covered by Medicare for any indication. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of auricular nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve use of an auricular percutaneous electrical nerve stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the CPAP device and humidifier provided
on February 22, 2021.

You asked the Plan to waive the coinsurance for the CPAP device and humidifier. You say that you do not
understand why you are being billed two separate prices when it is a part of the CPAP machine. The Plan
denied your request. The Plan says you have been asked to pay 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 20%
coinsurance for each Medicare-covered item.

You have been asked to pay $20.60 which is 20% of the allowed amount for the CPAP device. The allowed
amount is $103.02. ($103.02 x 20% = $20.60). You have been asked to pay $2.71 which is 20% of the allowed
amount for the humidifier. The allowed amount is $13.57. ($13.57 x 20% = $2.71). ($20.60 + $2.71 = $23.42).
The CPAP device and humidifier fall within the "Durable medical equipment (DME) and related supplies"
benefit category. The record shows the CPAP device, and the humidifier are considered separate items.

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 the CPAP device and humidifier provided on February 22,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for an office visit, injection of immune globulin
and an injection of diphenhydramine provided on January 13, 2021.

You asked the Plan to waive the cost-share for an office visit and injections. You say that you disagree with the
charges. The Plan denied your request. The Plan says the cost-share 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 20%
coinsurance for Medicare Part B prescription drugs. Your contract with the Plan also clearly says that you must
pay a $35 copayment for physician/practitioner services, including doctor's office and specialist visits.

You have been asked to pay a 20% coinsurance for injections and a $35 copayment for a specialist office visit.
The allowed amount of the claim for the injection of immune globulin is $13,660.80, resulting in a coinsurance
of $2,732.16. The allowed amount of the claim for the injection of diphenhydramine is $0.62, resulting in a
coinsurance of $0.12. The EOC confirms that $35 is the required copayment for the specialist office visit. The
EOC also confirms that $2,767.28 is the correct cost-sharing for these services ($2,732.16 + $0.12 + $35 =
$2,767.28). An office visit and injections fall within the Medicare Part B prescription drugs and
physician/practitioner services, including doctor's office 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 cost-share for a specialist office visit for infusion into a vein for therapy (96563,96374, 96366, 96375), an
injection of immune globulin (J1599) and an injection of diphenhydramine (J1200) provided on January 13,
2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on November 4, 2020, by an OON
provider.

You asked the Plan to pay for lab tests. You say that your lab performed all the tests that were ordered by the
referring physician. The Plan denied your request. The Plan says the referring provider is out-of-network. The
Plan says that prior authorization from a participating provider 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 had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for lab tests provided on November 4, 2020, by an
OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic Laryngoscopy (31575) provided on March 1, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $375 copayment for Medicare-covered outpatient hospital surgery services. 

You have been asked to pay $169.76 for the outpatient surgery provided. This amount is the Plan allowed amount which is less than the applicable copayment for this service.

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 diagnostic Laryngoscopy (31575) provided on March 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-shares for office visits, acupuncture visits and manual therapy visits provided November 24, 2020, to December 29, 2020.

You asked the Plan to waive the cost-shares for office visits, acupuncture visits and manual therapy visits. You say that you disagree with the charges. The Plan denied your request. The Plan says the cost-shares 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 $50 copayment for physician/practitioner services, including doctor's office visits and specialist visits. Your contract with the Plan also clearly says that enrollees must pay a $20 copayment for chiropractic services including acupuncture. Your contract with the Plan also clearly says that enrollees must pay a $40 copayment for outpatient rehabilitation services. 

You have been asked to pay a $50 copayment for each office visit, a $20 copayment for each acupuncture visit and a $40 copayment for each manual therapy visit. The EOC confirms that $50 is the required copayment for the specialist office visit ($50 x 2 visits = $100). The EOC also confirms that $20 is the required copayment for chiropractic services including acupuncture visit ($20 x 6 visits = $120). The EOC also confirms that $40 is the required copayment for outpatient rehabilitation services including manual therapy. You have been asked to pay a copayment of $32.73, which is less than the Plan's contracted amount (32.73 x 6 visits = $196.38). The EOC also confirms that the total cost share of $416.38 is the correct cost-share for these services. An office visit falls within the physician/practitioner services, including doctor's office visits benefit category. An acupuncture visit falls within the chiropractic services benefit category. A manual therapy visit falls within the outpatient rehabilitation services 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 cost-shares for two (2) office visits (99213), six (6) acupuncture visits (97810) and six (6) manual therapy visits provided November 24, 2020, to December 29, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services with two aides (G0156).

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not medically necessary.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that these services are not medically necessary and reasonable. Our physician reviewer found that the records do not show that home health aide services with two aides, 24 hours per day, 7 days per week meet the definition of home health aide services as the requested services are not part time or intermittent. Additionally, you were noted to be discharged from home care on May 3, 2021 and transferred to a skilled nursing facility under hospice care on May 7, 2021.

The request for two aides, 24 hours per day, 7 days per week is not reasonable and necessary for the treatment of your illness or injury by skilled professional staff. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide services with two aides (G0156).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a diagnostic breast ultrasound.

You asked the Plan to pre-approve a diagnostic breast ultrasound. You say that you have been recommended for this procedure since 2015 and health care has paid for this procedure since 2018. The Plan denied your request. The Plan says the requested diagnostic ultrasound is being requested for cancer screening therefore not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The test at issue in this appeal, a diagnostic breast ultrasound, is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve a diagnostic breast ultrasound.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy visits provided on
September 11, 2020, to September 30, 2020.

You asked the Plan to waive the copayment for physical therapy visits. You say that you did not receive
services on September 23, 2020 and September 30, 2020. 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 $35
copayment for each outpatient rehabilitation service.

You have been asked to pay a $35 copayment for physical therapy. The total amount owed on this claim is $140 ($35 x 4 visits = $140). The EOC confirms that $35 is the required copayment for this service. The records show that you received physical therapy services on September 23, 2020 and September 30, 2020. Physical therapy falls within the outpatient rehabilitation services 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 physical therapy visits provided on September 11, 2020, to September 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the general health panel provided on November 24, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this is not a
covered service.

The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a noncovered
code.

You have requested payment for services billed under code 80050. Medicare does not cover or pay for services
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel
provided on November 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) provided on January 25, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under your contractual policy or by Medicare.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99203) provided on January 25, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from
November 21, 2020, to December 20, 2020.

You asked the Plan to pay for the SNF services. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive any skilled services during the dates of service in question.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 pay for the SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 pay for the skilled nursing facility (SNF) services provided from November 21, 2020, to December 20, 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 this is the appropriate level of care for the enrollee and his needs. The Plan denied your request. The Plan says the enrollee is receiving medically necessary acute care.

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 physician reviewer found that the enrollee was admitted to the acute care hospital for seizures and encephalopathy. He has remained unresponsive and there have been no attempts at weaning from the ventilator. The enrollee is receiving appropriate care at the present acute care hospital. He does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that he requires that are not available at the health care setting being offered by the health plan. Therefore, the requested LTACH services are not medically 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364) and to
pay more for the root canal (D3330) provided on October 22, 2020 by an OON provider.

You asked the Plan to pay for the cone beam CT capture and interpretation or pay more for the root canal. You say that the enrollee should have only been charged 50% of the bill. The Plan denied your request. The Plan says the cone beam CT capture and interpretation is not a covered benefit, and the enrollee is responsible for 50% of the allowed amount for the root canal. The Plan also says that these services were rendered by an OON provider, and the provider is allowed to bill the difference of the allowed amount and their billed amount.

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 cone beam CT capture and interpretation (D0364) is not among those covered under this benefit. The contract says that the enrollee is responsible for 50% of the allowed amount for the root canal, and the enrollee is also responsible for the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364) and to pay more for the root canal (D3330) provided on October 22, 2020 by an OON provider.