Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tumor treatment field therapy (TTFT).
You asked the Plan to pre-approve the TTFT. You say that recurrent Glioblastoma is included the NCCN guidelines for TTFT. The Plan denied your request. The Plan says the criteria for coverage of TTFT have not been met.
The Plan must follow Medicare rules. Medicare rules say that the use of TTFT for any indications other than newly diagnosed GBM will be denied as not reasonable and necessary. We looked at the file and Medicare rules. The records show that the enrollee's GBM diagnosis is not new, but rather recurrent. Based on this information, we decided that Medicare rules for coverage of the TTFT have not been met. Therefore, we decided that the Plan does not have to pre-approve Tumor treatment field therapy (TTFT).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the pacemaker placement provided on July 18, 2019.
You asked the Plan to waive the coinsurance for the pacemaker placement. You say that the bill puts you in a hard place financially. You say that you want the bill dismissed. The Plan denied your request. The Plan says the coinsurance 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 10% coinsurance for Medicare-covered surgery or other services at an outpatient hospital or ambulatory surgical center. You have been asked to pay $748.78, which is less than the standard 10% coinsurance for the pacemaker placement because you met your maximum out-of-pocket. The pacemaker placement falls within the "Outpatient Surgery and Other Medical 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 coinsurance for the pacemaker placement provided on July 18, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the services provided to the enrollee by an out-of-network provider from May 8, 2019 through May 13, 2019.You asked the Plan to pay forthe services. You say that the claim should be paid.The Plan denied your request. The Plan says that the inpatient stay was not medically necessary; therefore, all services rendered during that stay have been denied.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 planfollows these rules.The enrolleewas referred for the services by a network facilitythe physician is not a contract provider. The file does not show that the plan provided notice that the services would not be covered. Under Medicare rules, this means the services is considered approved by the plan.Therefore, we decided that the Plan has to pay forthe services provided to the enrolleeby an out-of-network provider from May 8, 2019 through May 13, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from June 11, 2019 through June 16, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is 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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from June 11, 2019 through June 16, 2019.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045) provided on July 8, 2019.
You asked the Plan to pay for the chest x-ray. You say that the service was provided and payment should be
rendered. The Plan denied your request. The Plan says based on the documentation provided, the claim was
processed correctly.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or
provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare
coverage criteria have been met.
We looked at the file and Medicare rules. Specifically, medical records were not provided. The services are not
able to be corroborated without this documentation. Based on this information, we decided that Medicare rules
for coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for
a chest x-ray (71045) provided on July 8, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the step therapy requirement is not met.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the submitted records show that you
have a diagnosis of anemia with chronic kidney disease. You have not tried and failed the plan's required drug
of Retacrit. The records do not show that Retacrit would be less effective or have adverse effects; therefore,
Aranesp is not reasonable or medically necessary at this time.
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 Aranesp.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 5, 2019 by out of network provider.
You asked the Plan to pay for the home visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says medical records are required in order to determine the medical necessity of the retro-authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
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. The provider did not include medical records to determine the medical necessity for a retro-authorization. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on June 5, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on August 7, 2019.
You asked the Plan to pay for drug tests. You say that you are appealing with records. The Plan denied your
request. The Plan says the denial of payment for these services is correct, because the documentation submitted
did not include a physician order, lab requisition, or medical records stating exactly which tests were to be
performed.
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 physician order or
clear intent to order the specific lab tests 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 August 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from July 23, 2019 to October 11, 2019.
You asked the Plan to pay for the glucose monitor (E2100), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from July 23, 2019 to October 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on April 15, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on April 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services (73100) services provided on February 12, 2019.
You asked the Plan to pay for the radiology services. 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the radiology services (73100) services provided on February 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve enteral formula (B4150).
You asked the Plan to pre-approve the enteral formula. You say that you feel that this is medically necessary. The Ensure is helping you and you'd like to continue with it but it is expensive as you have been buying the formula out of pocket. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan does not have to pre-approve enteral formula (B4150).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that the requested diapers are medically necessary. You say that the enrollee currently requires 6 diaper changes per day. The Plan denied your request. The Plan says diapers are not a covered benefit through Medicare or under the Plan contract.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic screening testing provided on May 15, 2019.
You asked the Plan to pay for genetic test. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this test was ordered by telemedicine which is a Medicare prohibited action.
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, genetic test, was 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 pay for genetic screening testing provided on May 15, 2019.
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 the enrollee has been doing well on this medication.
The Plan denied your request. The Plan says drug coverage is limited to Part B covered drugs.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomographic (CT) colonography screening.You asked the Plan to pre-approve CT colonography screening. You say that you feel that this is the safest screening method because the enrollee had a defibrillator put in place.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Computed Tomographic (CT) colonography screening is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that CT colonography screening is not covered by Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT colonography screening have not been met.Therefore, we decided that the Plan does not have to pre-approveComputed Tomographic (CT) colonography screening.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the guidance for localization of target volume for delivery of radiation treatment (77387) provided on July 24, 2019.
You asked the Plan to pay for the guidance. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare guidance says procedure code 77387 has a status code of "I."
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 CPT code 77387 is not supported in the medical record. Specifically, per the 2019 Physician Fee Schedule, 77387 has a status code of I. This means that 77387 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the guidance have not been met. Therefore, we decided that the Plan does not have to pay for the guidance for localization of target volume for delivery of radiation treatment (77387) provided on July 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the extractions, bone graft, and implants to be provided.
You asked the Plan to pre-approve the dental services. You say that the few teeth that are remaining in your
lower jaw are crumbling. You say that you are unable to eat away from your home. You also say that people
have a hard time understanding you when you speak. The Plan denied your request. The Plan says covered
services are limited to surgery of the jaw or related structures, setting fractures of the jaw or facial bones,
extraction of teeth to prepare the jaw for radiation treatments of abnormal growth cancer disease, or services
that would be covered if provided by a physician.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the extractions, bone
graft, and implants to be provided.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services provided to the enrollee on June 7, 2019.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for office visit services provided to the enrollee on June 7, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment the ambulance ride provided on July 23, 2019.
You asked the Plan to waive the copayment the ambulance ride. You say that the ambulance transport was unnecessary and you should not be responsible for this amount. The Plan denied your request. The Plan says you have been charged 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 a $175 copayment for each one-way Medicare-covered trip. You have been asked to pay a $175 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance 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 the ambulance ride provided on July 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation billed for services provided on July 5, 2019.
You asked the Plan to pay for the sedation services. The Plan denied your request. The Plan says the billed services are not supported by documentation.
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 codes 99152 and 99153 are moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial and each additional 15 minutes. We find that CPT codes 99152 and 99153 are not supported in the medical record. Specifically, the records provided do not show that the presence of an independent trained observer to assist in the monitoring of the enrollee was required or provided. Based on this information, we decided that Medicare rules for coverage of the sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation billed for services provided on July 5, 2019.