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

We decided that the Plan does not have to pre-approve Keytruda (J9271).
You asked the Plan to pre-approve Keytruda. You say that this drug is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
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 Keytruda. Our reviewer says that the requested service is not medically reasonable and necessary. Our physician reviewer found you are a 76-year-old who has been diagnosed with right upper lobe non-small-cell lung carcinoma diagnosed in 2017. In this case, the requested drug is not FDA-approved without documentation of PD-L1 of >=1%. In addition, there is no Medicare-approved compendia support for the requested drug.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9271).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic (D2740) for tooth #6.
You asked the Plan to pre-approve a crown for tooth #6. You say that the crown is medically necessary. The
Plan denied your request. The Plan says this service was previously covered for this tooth in 2017 and therefore
is not eligible for coverage at this time.
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 covers a crown for
tooth 6 once per 60 months.
We looked at the file and Medicare rules. The Plan provided documentation showing that a crown was covered
for tooth #6 on December 12, 2017. Based on this information, we decided that the Plan's rules for coverage of
a crown for tooth #6 have not been met. Therefore, we decided that the Plan does not have to pre-approve a
crown - porcelain/ceramic (D2740) for tooth #6.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home-delivered meals.

You asked the Plan to pre-approve the additional home-delivered meals. You say that you are handicapped and, in a wheelchair and you unable to go to the grocery store. The Plan denied your request. The Plan says the Plan's benefit allows for 14 meals after a hospital stay. You have exhausted the 14-meal allotted benefit.

The Plan contract says that home-delivered meals are a supplemental benefit for up to 14 healthy frozen meals delivered to your home. 

We looked at the file and the Plan's rules. The file shows that you have exhausted the 14-meal allotted benefit. Therefore, we decided that the Plan does not have to pre-approve additional home-delivered meals.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the replacement of missing or broken teeth (each tooth) for dentures (D5520) provided on February 10, 2021.
You asked the Plan to pay for the denture repairs. You say that you thought you had coverage for these services. The Plan denied your request. The Plan says they have paid for one of the denture repair procedure codes, but you are responsible for the four other tooth replacements as the Plan only covers one denture repair procedure code per year. The benefit 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, denture repairs are requested in a
frequency that is not covered under this benefit. Documentation shows that you had 5 denture teeth replaced on the date in question, which requires 5 separate procedure codes (one per tooth). The Plan has paid for one procedure code as stated in the contract. Therefore, we decided that the Plan does not have to pay for the remaining replacements of missing or broken teeth (each tooth) for dentures (D5520) provided on February 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional trips that go beyond the allotted 20-trip limit.

You asked the Plan to pre-approve additional routine transportation. You say that you need additional trips to appointments. The Plan denied your request. The Plan says once your 20-trip limit is exhausted you are not eligible for additional trips.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 20 trips per year.

We looked at your request, the records in the case file, and the rules. The Plan provided documentation
showing that you have taken 19 routine transports in 2021. The Plan will cover a maximum of 20 trips per year. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional trips that go beyond the allotted 20-trip limit.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on January 28, 2021 and the urography and sigmoidoscopy provided on February 5, 2021.
You asked the Plan to waive the copayment for the MRI, urography and sigmoidoscopy. You say that the tests were needed as a result of an injury that happened while under the care of the hospital. You say that you should not have to pay for these tests or for the bills. The Plan denied your request. The Plan says the copayments 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 $150 per day, per provider, for Medicare-covered diagnostic radiology, $35 per day, per provider, for Medicare-covered x-ray services from an in-network provider and $290 for each in-network Medicare-covered outpatient hospital facility visit. You have been asked to pay a total of $475 for the MRI, urography and sigmoidoscopy.
Date of Service
Service
Standard Copayment
Member Liability
January 28, 2021
MRI
$150
$150
February 5, 2021
Urography
$35
$35
February 5, 2021
Sigmoidoscopy
$290
$290
TOTAL:
$475
The MRI and urography fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The sigmoidoscopy 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 the MRI provided on January 28, 2021 and the urography and sigmoidoscopy provided on February 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide acute inpatient hospital care for the approved arthroplasty.

You asked the Plan to provide acute inpatient hospital care. You say that the enrollee needs total hip arthroplasty with inpatient services. The Plan denied your request. The Plan says there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.

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 provide 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 the planned procedure is listed under CPT code 27130 which is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The review has determined that the record does not show that for the total hip replacement the physician reasonably expects that the patient's necessary hospital care will span two 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 provide acute inpatient hospital care for the approved total hip arthroplasty.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on March 17, 2021.
You asked the Plan to reimburse you for the hearing aids. You say that the Plan's benefits overview indicates that hearing aids are covered. The Plan denied your request. The Plan says hearing aid must be purchased through the Plan's hearing aid provider to be covered under the hearing aid services offered by your Plan.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when purchased from a Plan hearing aid provider. We looked at the file and the Plan's rules. The file shows that the hearing aids were not purchased from the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on March 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. 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. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program.
Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two crowns (D2740 x2).

You asked the Plan to pre-approve the crowns. The Plan denied your request. The Plan says crown (D2740) is not covered under the enrollee's benefit plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two crowns (D2740 x2).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Daratumumab injections to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve Daratumumab injections. You say that this care is necessary while you are out of the country. The Plan denied your request. The Plan says this is not considered emergent or urgent care because you are only planning to go out of the country.
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. Because you are only planning on going out of the country and are not there yet, the care would not be considered emergent or urgent. 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 Daratumumab injections to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266), bone replacement graft (D7953), implant placement (D6010), an initial 15 minutes of intravenous (IV) sedation (D9239), and an additional 15 minutes of IV sedation (D9243 x 3).
You asked the Plan to pre-approve the guided tissue regeneration, bone replacement graft, implant, and sedation services. You say that the services are necessary. The Plan denied your request. The Plan says guided
tissue regeneration is not listed as a covered service. The Plan says that bone replacement graft is not listed as a covered service. The Plan says that implant placement is not listed as a covered service. The Plan says that
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve guided tissue regeneration (D4266), bone replacement graft (D7953), implant placement (D6010), an initial 15 minutes of intravenous (IV) sedation (D9239), and an additional 15 minutes of IV sedation (D9243 x 3).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve otolaryngology (ear, nose, and throat or ENT) office services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve ENT services. You say that you have been trying to get an appointment for 2 months. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network ENT specialist.
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 otolaryngology (ear, nose, and throat or ENT) office services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), bitewing x-rays (D0274), panoramic x-ray (D0330), and prophylaxis (D1110) provided on August 10, 2020 by an OON provider.

You asked the Plan to pay for the comprehensive oral evaluation, bitewing x-rays, panoramic x-ray, and prophylaxis. You say that you called to see what provider was in-network in your area. You also say that you were misinformed about this provider's participating status. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that no benefits are available for procedures performed by OON providers.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON. The record shows that you did not contact the Plan prior to this date of service asking for in-network providers. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), bitewing x-rays (D0274), panoramic x-ray (D0330), and prophylaxis (D1110) provided on August 10, 2020 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (72192) provided on February 2, 2021.

You asked the Plan to pay for a CT scan. You say that this was a separate and distinct procedure. The Plan denied your request. The Plan says this is not separately payable without a modifier.

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 72192 has a bundled relationship with code 74176 and cannot be paid as billed. This code cannot be paid as a separate line item without an appropriate modifier. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan (72192) provided on February 2, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on October 2, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare
denies coverage for all cardiovascular risk assessment panels - except the basic lipid panel - for symptomatic
patients with suspected or documented cardiovascular disease.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The plan follows these rules.
This testing was ordered by an in-network provider. The file does not show that the plan provided notice that
genetic testing would not be covered. Under Medicare rules, this means genetic testing is considered approved
by the plan. Therefore, we decided that the Plan has to pay for genetic testing provided on October 2, 2020.
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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care. The Plan denied your request. The Plan says the enrollee can safely receive services needed in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 there are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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 acute inpatient rehabilitation facility (IRF) admission and services.