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

We decided that the Plan has to pre-approvea Durvalumab injection (J9173).You asked the Plan to pre-approvethe Durvalumab. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says that this drug is not medicallynecessary for the treatment of the member's condition.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Durvalumab. Our reviewer says that Durvalumab for the first line treatment of non-small cell lung cancer is supported by the medical literature. Our physician reviewer found this patient has largely stable disease on recent PET and continuation of durvalumab is reasonable and 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 Durvalumab have been met.Therefore, we decided that the Plan has to pre-approvea Durvalumab injection (J9173).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 pay for inpatient hospital care provided to the enrollee from
November 29, 2019 through January 16, 2019.
You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid. The Plan denied
your request. The Plan says Payment is not allowed for this claim because an itemized bill is required to
process this claim. The Plan states to please submit this itemized bill to the claims address on the back of the
members ID Card for claim reconsideration.
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 inpatient hospital care have not been met. Payment is not allowed
for this claim because an itemized bill is required to process this claim. The Plan states to please submit this
itemized bill to the claims address on the back of the members ID Card for claim reconsideration. Therefore,
we decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from
November 29, 2019 through January 16, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a chest CT angiogram for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee has occasional dyspnea, but a normal respiratory exam, a normal cardiac exam, a normal chest x-ray, a recent stress test about one year ago, and a RBBB but otherwise normal ECG. In this circumstance the documentation provided does not support the medical necessity for a chest CT angiogram. RBBB in isolation is usually a benign finding and there is nothing else on the ECG to indicate ischemia, cor pulmonale or other abnormality. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a chest CT angiogram for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional transportation. You say that not making it to your follow-up appointments could affect your health in a negative way. The Plan denied your request. The Plan says your benefit only allows 12 trips for this service.
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 12 one-way trips per year. We looked at your request, the records in the case file, and the rules. Once you have used 12 one-way trips, you will have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from February 18, 2020 through February 19, 2020 provided by an in-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were not aware that there was a copay for inpatient hospital care. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received inpatient hospital care from February 18, 2020 through February 19, 2020 provided by an in-network provider. You are asked to pay a $200 copayment for the inpatient hospital care. Your EOC states, you pay a $200 copayment for medically necessary in-network inpatient hospital care. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care from February 18, 2020 through February 19, 2020 provided by an in-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelongterm acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that transfer to an LTACH is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not 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 based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for respiratory failure. The enrollee was intubated/ventilated and subsequently received a tracheotomy. He has since been weaned for the ventilator to a tracheotomy collar. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. Medicare criteria for transfer are not met. 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-approvelong term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve refraction services (92015) and frames (V2020) and lenses (V2784).You asked the Plan to pre-approve the vision services. You say that the enrollee's vision went from 400 to 850 in less than a year and another eye exam and glasses are medically necessary.The Plan denied your request. The Plan says this request exceeds the benefit frequency limitation.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers only 1 supplemental routine eye exam every year and $275 eyewear benefit every two years.We looked at the file and the Plan's rules. The plan covers 1 supplemental routine eye exam every year and $275 eyewear allowance every two years. The records show that the enrollee received an eye exam on 2/24/2020 and the eyewear allowance was used on 3/16/2019. Therefore, these benefits are exhausted. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.Therefore, we decided that the Plan does not have to pre-approve refraction services (92015)and frames (V2020) and lenses (V2784).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear provided on March 6, 2020.
You asked the Plan to pay for the eyewear. You say that you received the benefit overview stating that the Plan pays $175 yearly for glasses/contacts. The Plan denied your request. The Plan says you exhausted your maximum benefit allowance.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. You used $125 of your allowance toward eyeglasses on June 14, 2019. Since a full 12 month period had not passed between that benefit use and the eyeglasses allowance that was used on March 6, 2020, only the $50 increase in the eyeglasses allowance for the 2020 plan year was available to be paid towards the eyeglasses received. Therefore, we decided that the Plan does not have to pay for the eyewear provided on March 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forambulance services on January 14, 2020 and February 12, 2020.You asked the Plan to pay forthe ambulance transports. You say that because of a fall this is the only way you can get to medical appointments.The Plan denied your request. The Plan says the origin and destination of a doctor's office is not covered.The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to and from a doctor's office.Therefore, we decided that the Plan does not have to pay forambulance services on January 14, 2020 and February 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethedraining of the Bursa and dexamethasone injection to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe draining of the Bursa and dexamethasone injection. The Plan denied your request. The Plan says that there are in network specialists available to treat the member for this service.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-approvethe draining of the Bursa and dexamethasone injection to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvelong term acute care hospital (LTACH) services.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysan assessment from a medical person must show that you will need long-term 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found you are currently undergoing treatment at an ACH for respiratory failure. You required intubation/ventilation and subsequently received a tracheotomy. You have since been weaned from the ventilator. There is no evidence that you require services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. You can remain at the current ACH until such time no acute services are required. You can then be transferred/dischargedto a lower level of care for any ongoing long term care needs.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 Plandoes not haveto pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forambulance services provided on September 12, 2018.You asked the Plan to pay forthe ambulance services. You say that you were unable to get the enrollee's insurance information.The Plan denied your request. The Plan says the claim was untimely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the ambulance services was not filed until December 10,2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forambulance services provided on September 12, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a thromboendarterectomy (35371) provided on February 11,
2020.
You asked the Plan to pay for the thromboendarterectomy. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not
support the service 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 CPT Code Manual definition of code 35371 is Thromboendarterectomy, including patch graft,
if performed; common femoral.
We asked our coder 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 thromboendarterectomy. Our reviewer says that CPT
code 35371 does not meet criteria for billing or reimbursement consideration. Our coder reviewer found the
submitted documentation was reviewed and does not indicate that this procedure was performed.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the thromboendarterectomy have not been met. Therefore, we decided that the
Plan does not have to pay for a thromboendarterectomy (35371) provided on February 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on December 3, 2019.
You asked the Plan to pay for drug tests. You say that you have submitted a valid laboratory requisition form.
The Plan denied your request. The Plan says the denial of payment for these services is correct, because the
documentation submitted does not support a valid order for this testing.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician
order or clear intent to order the specific lab services billed on this claim. Based on this information, we
decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan
does not have to pay for drug testing provided on December 3, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetherapy (97110 X10) and(97161, 97530, 97116, G0283 X10 EACH NO PA NEEDED), for the enrollee.You asked the Plan to pre-approvethe services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not 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 the services. Our physician reviewer found the medical records provided do not meet Medicare coverage for Therapy (97110 X10) and(97161,97530,97116,G0283 X10 EACH NO PA NEEDED) and are not medically necessary to improve a patient's current condition, to maintain the patient's current condition, or to prevent or slowfurther deterioration of the patient's condition. The patient was already ambulating at a level that did not need skilled physical therapy on April 27, 2020. The requested services under a physical therapist for the patient's wound care is not considered under accepted standards of medical practice to be a specific and effective treatmentfor the patient's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pre-approvetherapy (97110 X10) and (97161, 97530, 97116, G0283 X10 EACH NO PA NEEDED), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 test provided to the enrollee on March 10, 2020.
You asked the Plan to pay for the test. You say that this should be paid for. The Plan denied your request. The Plan says Medicare requires the use of CPT 81479 to report the Guardant360 testing.
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 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 test. Our reviewer says that the denied codes do not meet the criteria for billing or reimbursement consideration. Our physician reviewer found Medicare requires that CPT 81479 be reported for Guardant360 molecular pathology genomic profiling and that the unbundling of codes when performing this service is not appropriate. The various denied codes are not eligible for separate reimbursement. 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 test have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 test provided to the enrollee on March 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an 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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not require intensive physician or nursing supervision in an IRF. While the enrollee may benefit and participate in multiple therapies; his functional level does not require this in an 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis, comprehensive oral evaluation, complete series of intraoral x-rays, and bitewings provided from June 5, 2018 to May 2, 2019 by an OON provider.You asked the Plan to pay forthe prophylaxis, comprehensive oral evaluation, complete series of intraoral x-rays, and bitewings. You say that you damaged your thumb and needed an extra cleaning, because you were not able to floss properly.The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that you must use network providers to receive dental services.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.Therefore, we decided that the Plan does not have to pay for the prophylaxis, comprehensive oral evaluation, complete series of intraoral x-rays, and bitewings provided from June 5, 2018 to May 2, 2019 by an OON provider.Your complaint about your dissatisfaction with the Plan contracted providers is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.