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

We decided that the Plan does not have to pre-approve Opdivo.

You asked the Plan to pre-approve Opdivo. You say that the medication is 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 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 Opdivo. Our reviewer says that the medication is not medically necessary. Our physician reviewer found Nivolumab (Opdivo) is FDA approved for the treatment of squamous cell cancer of the esophagous but not for adenocarinoma of the esophagous. Use for adenocarcinoma of the esophagous is not supported by major drug compendia or the medical literature. The service is not reasonable or 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 Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a participating provider on October 12, 2020, to December 4, 2020.
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you thought this would be covered because it was within 90 days of your surgery. The Plan denied your request. The Plan says the correct coinsurance has been applied.
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 durable medical equipment/in-network. You have been asked to pay less than a 20% coinsurance of the allowed amount for durable medical equipment. The total allowed amount is $794.81. The total 20% coinsurance is $158.96 ($794.81 x 20% = $158.96). The total amount you are being asked to pay is $89.91. durable medical equipment falls within the durable medical equipment/in-network 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 durable medical equipment provided by a participating provider on October 12, 2020, to December 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit.

You asked the Plan to waive the copayment for an office visit. You say that this was an annual wellness visit and you should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $15 copayment for office visits.

The medical records show that you received services beyond an annual wellness exam. Therefore, you are responsible to pay a $15 copayment.

You have been asked to pay the total copayment amount of $15 for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 an office visit.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health services.

You asked the Plan to pre-approve the services. You say that this is necessary because you have palsy. The Plan denied your request. The Plan says no skilled services are required.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the patient's condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. There is no need for complex wound care. Your needs do not require a professional skilled nurse. You have been educated in disease management. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a maintenance program.

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-approve continued home health services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care.

You asked the Plan to pre-approve home health 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 home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 home health care. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. As such, home health services, including home health aide services, are not shown to be medically necessary or reasonable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve home health care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic CGM products (K0553) provided on October 14, 2020.
You asked the Plan to pay for CGM products. You say that the requested items are medically necessary. The Plan denied your request. The Plan says medical records do not support a need for the requested items.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day. Based on this information, we decided that Medicare rules for coverage of CGM products have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic CGM products (K0553) provided on October 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for inpatient hospital services provided from July 26, 2020, to July 27, 2020.
You asked the Plan to waive the coinsurance for inpatient hospital services. You say that you were told that hospice care would be fully covered. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct 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). The enrollee's contract with the Plan clearly says that enrollees must pay 4% coinsurance for inpatient hospital care. The medical records show that the enrollee received inpatient hospital services from July 26, 2020, to July 27, 2020. The total allowed amount is $11,869.15 and 4% of that is $474.77. The enrollee has been asked to pay the total coinsurance amount of $474.77 for inpatient hospital services. Inpatient hospital services fall within the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for inpatient hospital services provided from July 26, 2020, to July 27, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture and complete mandibular denture.

You asked the Plan to pay for the complete maxillary denture and complete mandibular denture. You say that you would like these services to be covered. The Plan denied your request. The Plan says dentures are not covered under your 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 pay for the complete maxillary denture and complete mandibular denture.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric services provided from September 2, 2020, to September 14, 2020.

You asked the Plan to pay for the inpatient services. You say that the facility is exempt because it is an inpatient psychiatric hospital. The Plan denied your request. The Plan says claims must include the appropriate POA indicator for the principal and all secondary diagnoses.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

We looked at the file and the rules. The provided claim does not show that the services were billed with a valid POA indicator. Based on this information, we decided that Medicare rules for coverage of the inpatient services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient psychiatric services provided from September 2, 2020, to September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the prescription services provided to the enrollee.

You asked the Plan to pay for the prescription services. You say that the enrollee is a veteran and the services should be covered. The Plan denied your request. The Plan says services received by a veteran in a Veteran Affairs facility are not covered unless under emergency scenarios.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the prescription services have not been met. This enrollee received a prescription, not emergency services. Page 136 of the enrollee's EOC shows that services received by a veteran in a Veteran Affairs facility are not covered unless under emergency scenarios Therefore, we decided that the Plan does not have to pay for the prescription services provided to the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department services (99285) provided on November 24, 2020.
You asked the Plan to pay for the emergency department services. You say that you would like reconsideration because this service was billed with the appropriate diagnosis code. The Plan denied your request. The Plan says the ICD 10 coding manual indicates that N73.0 is a female only diagnosis and per review of medical record, the member is a male patient.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 99285 is not supported in the record. Specifically, this claim was billed with a diagnosis code that is specific to females. The record indicates that this member is a male. Based on this information, we decided that Medicare rules for coverage of the emergency department services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department services (99285) provided on November 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Irinotecan.

You asked the Plan to pre-approve Irinotecan. 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 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 Irinotecan. Our reviewer says that the medication is not necessary. Our physician reviewer found for the treatment o HER2 positive progressive metastatic rectal cancer irinotecan-based therapy with Trastuzumab is not FDA approved, supported by major drug compendia, or the medical literature. The service is not reasonable or 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 Irinotecan have not been met. Therefore, we decided that the Plan does not have to pre-approve Irinotecan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodic oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274).

You asked the Plan to reimburse you for the dental services. You say that you have submitted this claim twice with no response. You say that your copy of your benefit states that you have coverage for an out of network provider. You also say that your Medicare agent advised you should be reimbursed for the services. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan says that payment cannot be made for dental services performed by a dentist who has opted out of Medicare.

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 and the services are listed as covered, dental services performed by a dentist who has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the periodic oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse the enrollee additionally for the skilled nursing facility services.

You asked the Plan to reimburse the enrollee additionally for the SNF services. You say that the Plan has not reimbursed the enrollee enough for the SNF services. The Plan denied your request. The Plan says the enrollee was reimbursed correctly up to the Medicare allowable.

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 enrollee's must pay 20% coinsurance for Skilled Nursing Facility care.

The enrollee has been reimbursed all but the 20% coinsurance for the SNF services. This means that the enrollee has been asked to pay the correct amount based on their contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when enrolling in the Plan. Therefore, we decided that the Plan does not have to reimburse the enrollee additionally for the skilled nursing facility services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan of the chest (71250).
You asked the Plan to pre-approve a CT scan of the chest (71250). You say that the requested CT scan of the chest is medically necessary. The Plan denied your request. The Plan says the requested CT scan of the chest 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 a CT scan of the chest (71250). Our reviewer says that the requested CT scan of the chest is not medically necessary. Our physician reviewer found the enrollee is currently smoking and has a 2 pack per week history for 15 years. The enrollee has had weight loss, but no cough, no shortness of breath, and the pulse oximeter reading is 100%. The request is for a standard CT scan of the chest. At issue is whether a standard CT scan of the chest for the enrollee is a covered service under Medicare rules. Medicare rules indicate that CT scans are covered if there is literature to support its use for the patient's condition and the scan is reasonable and necessary for the patient. In this case, the provider has ordered a standard CT scan of the chest. The medical records provided indicate that a low dose CT scan was planned. The record provided does not support the requested service. The requested service is not medically reasonable and necessary for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan of the chest (71250) have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan of the chest (71250).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee.

You asked the Plan to pay for this service. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 out of network physician services provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the immune globulin injections and intravenous infusions provided on July 2, 2020 and July 30, 2020.
You asked the Plan to waive the coinsurance for the immune globulin injections and intravenous infusions. You say that similar charges were adjusted as this care was for a rare disease. You say that you need financial help. 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 20% coinsurance for Medicare Part B covered drugs from an in-network provider. Cost shares listed will apply to administration of drugs in all places of treatment. You have been asked to pay a total of $856.74 for the immune globulin injections and intravenous infusions.
The immune globulin injections and intravenous infusions fall within the "Medicare Part B prescription drugs" 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 immune globulin injections and intravenous infusions provided on July 2, 2020 and July 30, 2020.