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

We decided that the Plan does not have to pre-approve the padcev (J9177), keytruda (J9271), and granisetron hydrochloride (J1626).
You asked the Plan to pre-approve the padcev, keytruda, and granisetron. You say that the drugs are medically necessary. The Plan denied your request. The Plan says there is no support for this regimen for the member's disease process in the compendia utilized by Medicare or in Medicare approved literature.
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 the padcev, keytruda, and granisetron. Our reviewer says that the service is not medically necessary. Our physician reviewer found the drugs are not FDA approved for the prior progression of their disease on prior therapy and its use is not supported my one of the major drug compendia or clinical research for patients that have progressed on prior treatments.
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 padcev, keytruda, and granisetron have not been met. Specifically, the drug compendia does not support the use of these drugs for the enrollee. This means the drugs are not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the padcev (J9177), keytruda (J9271), and granisetron hydrochloride (J1626).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve use of Orencia.
You asked the Plan to pre-approve Orencia. You say that the enrollee has severe intolerance to methotrexate which must be taken with Inflectra. The Plan denied your request. The Plan says that the denial of authorization for Orencia is correct, because the Plan requires a trial of Inflectra or Renflexis before it will approve Orencia.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Orencia. Our reviewer says that the enrollee meets the Medicare criteria for a step therapy exception for use of Orencia. Our physician reviewer found the records provided do not show that the enrollee has tried and failed the Plan's preferred drugs of Inflectra or Renflexis. However, the Medicare-approved drug compendia and the manufacturers of Inflectra and Renflexis state that these drugs should be used in combination with methotrexate for the management of rheumatoid arthritis. Although there is limited data in the compendia on the early use of Inflectra and Renflexis without concomitant methotrexate, long-term experience indicates that it is often necessary to use these drugs with another disease modifying agent to achieve optimum control in patients with moderately to severely active disease. Therefore, given that the enrollee cannot tolerate methotrexate and given that Orencia is clearly labelled as appropriate for monotherapy, an exception to the Plan's step therapy criteria is 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 Orencia have been met. Therefore, we decided that the Plan has to pre-approve use of Orencia.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy administration (96413) and the tocilizumab injection (J3262) provided on February 27, 2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the services 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 20% coinsurance for Medicare Part B chemotherapy drugs. Additionally, you pay a 20% coinsurance for other Medicare Part B drugs and outpatient services.
You have been asked to pay $699.68 (Plan allowed amount of $3,498.40 x 20%) for the Medicare covered chemotherapy and Part B drug injection provided. 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 chemotherapy administration (96413) and the tocilizumab injection (J3262) provided on February 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the anti-reflective coating, per lens (V2750) provided October 29, 2020.
You asked the Plan to pay for the anti-reflective coating. You say that you were without your normal provider due to COVID and would like your eyewear covered. The Plan denied your request. The Plan says the eyewear has been reprocessed but the lens upgrade is not covered.
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 standard frames and lenses after cataract surgery. We looked at the file and the Plan's rules. Though the Plan covers standard frames and lenses after cataract surgery, upgrades are not covered. Therefore, we decided that the Plan does not have to pay for the anti-reflective coating, per lens (V2750) provided October 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of insulin use.
The Plan must follow Medicare rules. Medicare rules say that a continuous glucose monitor is only covered for
enrollees who are insulin-treated.
It does not appear that you use insulin. Based on this information, we decided that Medicare rules for coverage
of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a
continuous glucose monitor.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for Actigraphy testing, recording, analysis, interpretation and report (95803) provided December 21, 2020.
You asked the Plan to pay for actigraphy testing. You say that please review attached documentation and resubmit for payment. The Plan denied your request. The Plan says this service does not meet NCD/LCD criteria and is not covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules also say that Actigraphy can be measured as part of a sleep test but will not be paid for separately. Actigraphy is a non-covered service when it is not done as part of a sleep test or when it is used for monitoring. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of actigraphy testing have not been met. Therefore, we decided that the Plan does not have to pay for Actigraphy testing, recording, analysis, interpretation and report (95803) provided December 21, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network outpatient services.
You asked the Plan to pre-approve out of network providers. You say that you prefer to see a physician or provider outside of the network. The Plan denied your request. The Plan says there are practitioners in network who provide the care you need.
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 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. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve out of network outpatient services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiogram provided on December 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the echocardiogram. You say that the service for the facility was approved and the physician service should also be covered. The Plan denied your request. The Plan says no prior authorization was 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 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 echocardiogram provided on December 28, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from December 23, 2019, to December 28, 2019.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were only in the hospital for one or two days and received no meals or morphine shots. The Plan denied your request. The Plan says you were charged this copayment 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 a $300 copayment per day for days 1-5 for inpatient hospital care. You have been asked to pay a $300 copayment per day for days 1-5 for the inpatient hospital services. The medical records from this hospitalization clearly show that you were admitted on December 23, 2019 and discharged on December 28, 2019. 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 services you received from December 23, 2019, to December 28, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Conformis, customized knee implant (27447).
You asked the Plan to pre-approve the customized knee implant. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.
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 customized knee implant. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective/safe treatment for the noted pathology. Long term advantages regarding improved function and or pain reduction have not been documented in the medical literature at large. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception.
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 customized knee implant have not been met. Specifically, this service is considered experimental and the rules say that experimental and investigational devices are not covered. Therefore, we decided that the Plan does not have to pre-approve the Conformis, customized knee implant (27447).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services with dental codes D2740 and D9944.
You asked the Plan to pre-approve dental codes D2740 and D9944. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says dental codes D2740 and D9944 are not covered under the Plan's supplemental dental benefit.
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 dental services with dental codes D2740 and D9944.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an echocardiograph (93306) provided December 30, 2020.
You asked the Plan to pay for the echocardiograph. You say that the service was medically necessary. The Plan denied your request. The Plan says the number of units billed exceeds the number supported by the records.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We find that 2 units of CPT code 93306 are not supported in the medical record. The medical record only supports 1 unit of CPT code 93306. Based on this information, we decided that Medicare rules for coverage of the echocardiograph have not been met. Therefore, we decided that the Plan does not have to pay for an echocardiograph (93306) provided December 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the lateral sacral branches.
You asked the Plan to pre-approve RFA of the lateral sacral branches. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that injection services are only covered for certain indications.
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 RFA of the lateral sacral branches. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic low back pain and sacroilitis. The enrollee has had several prior spine surgeries. The enrollee had Right SI joint injection which produced 90% pain relief for two weeks and then a second injection which provided 80% pain for almost three months. The request is considered experimental/ investigational because of the wide variation in efficacy reported in the literature. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of RFA of the lateral sacral branches have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the lateral sacral branches.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided July 14, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the lab services performed are not supported in the medical record. Specifically, the place of service listed on the claim (81, laboratory) does not match the place of service detailed in the record (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided July 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ophthalmology visit to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve the ophthalmology visit. You say that you do not want to see any providers
affiliated with the same company. The Plan denied your request. The Plan says the provider is 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 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
an ophthalmology visit to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.
You asked the Plan to provide coverage for the additional transportation trips. You say that you need additional transportation for frequent visits to multiple providers. The Plan denied your request. The Plan says you have exceeded the limit of transportation trips by 4 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 24 one-way trips per year.
We looked at your request, the records in the case file, and the rules. 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 provide coverage for additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the hydration therapy rendered on May 26, 2020.
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 that the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that the services were rendered in the state of New Jersey and that Local Coverage Determination (LCD) L34960 is binding; however, there is no documentation in the file to support that the services were rendered in New Jersey. The claim dispute form lists a National Provider Identifier (NPI) number that is listed as located in New York. The Plan has not provided any further documentation or rules to support that the services are not payable. Therefore, we decided that the Plan has to pay for the hydration therapy rendered on May 26, 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 waive the copayment for the inpatient hospital services you received from January 26, 2021, to January 30, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you disagree with this copayment. The Plan denied your request. The Plan says you were charged this copayment 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 a $325 copayment per day for days 1-5 for inpatient hospital care.
You have been asked to pay a $325 copayment for each day you were in the hospital. You were an inpatient for four days, so you have been asked to pay a total of $1300 ($325 x 4 days = $1300.) 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 inpatient hospital services you received from January 26, 2021, to January 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment without transportation (A0998) provided on March 4, 2021.
You asked the Plan to pay for the ambulance response and treatment. You say that you called the Plan and were told that a copay for an ambulance was $50. You then called for an ambulance and did not expect to be charged the full bill. The Plan denied your request. The Plan says ambulance transportation services require a $50 copayment, but response and treatment at the scene without ambulance transportation is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on March 4, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without transportation (A0998) provided on March 4, 2021.