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

 
We decided that the Plan has to pre-approve PegFilgrastim (Neulasta) 6mg, SQ, day 2, every 28 days, 6 cycles 
for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there are no risk factors to develop low immunity. 
 
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 drug. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found the enrollee has a recent 
diagnosis of both Gleason 10 (5+5) prostate cancer and diffuse large B-cell lymphoma. In this caee, the 
enrollee has both a low risk (prostate, 1%) and higher risk (lymphoma (26%) of febrile neutropenia.  The 
enrollee will be receiving chemotherapy for both cancers. The requested drug is being prescribed for its Food 
and Drug Administration approved indication. The drug is safe and effective for the enrollee's condition.  The 
elements of the controlling Medicare rule are satisfied.  The requested service is recommended. 
 
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 drug have been met. Therefore, we decided that the Plan has to pre-approve 
PegFilgrastim (Neulasta) 6mg, SQ, day 2, every 28 days, 6 cycles for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says care could be received in another setting, such as skilled nursing facility, outpatient 
setting, or home health care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for thoracic vertebral and rib fractures after a fall. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care provided from April 12, 2019, to April 15, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim was a duplicate.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim are denied. We find that the claim at issue is a duplicate of a previously submitted claim. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care provided from April 12, 2019, to April 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis coded L1833 and the addition to lower extremity orthosis coded L2397 provided on October 14, 2020.
You asked the Plan to pay for the knee orthosis and the addition to lower extremity orthosis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 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. We find that CPT codes L1833 and L2397 are not supported in the medical record. Specifically, the documentation does not support any evidence of an established relationship between the enrollee and the ordering physician. Based on this information, we decided that Medicare rules for coverage of the knee orthosis and the addition to lower extremity orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis coded L1833 and the addition to lower extremity orthosis coded L2397 provided on October 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram provided on September 29, 2020.
You asked the Plan to waive the copayment for the electrocardiogram. You say that you got this during a physical and shouldn't have to pay. The Plan denied your request. The Plan says the copayment 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 per day for Medicare-covered tests. You have been asked to pay a $10 copayment for the electrocardiogram. The electrocardiogram falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Diagnostic tests are not included in the annual physical benefit. 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 electrocardiogram provided on September 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walker purchased out of network on August 29, 2020.
You asked the Plan to pay for this equipment. You say that this walker should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for this equipment.
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 Plan contract states durable medical equipment requires prior authorization. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 {{enter specific services at issue}} provided on August 29, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression (0275T) for the enrollee.
You asked the Plan to pre-approve these services. You say that the member meets guidelines for this procedure. The Plan denied your request. The Plan says that there is no documentation provided to support the enrollee is participating in an approved clinical study for evidence development.
The Plan must follow Medicare rules. Medicare rules say that percutaneous image-guided lumbar decompression is covered if you are enrolled in an approved clinical study. We looked at the file and Medicare rules. The file does not indicate the enrollee is enrolled in a clinical study. 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 percutaneous image-guided lumbar decompression (0275T) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the cystourethroscopy services provided on April 8, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed services cannot be verified.
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 52240 is cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; LARGE bladder tumor(s) We find that CPT code 52240 is not supported in the medical record. In this case, the medical records do state the size to indicate the tumor was large. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the cystourethroscopy services provided on April 8, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for myocardial perfusion imaging.

You asked the Plan to waive the deductible and copayment for myocardial perfusion imaging. You say that you were not made aware of the charges and cannot find them in the EOC. 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. The enrollee's contract with the Plan says that there is a $750 deductible. The enrollee's contract with the Plan also clearly says that after the $750 deductible has been met, enrollee's must pay a $200 copayment for nuclear medicine.

The enrollee received myocardial perfusion imaging. The record shows that the enrollee had only paid $125.98 toward the $750 deductible prior to receiving the services. Therefore, the enrollee is responsible to pay the remaining deductible balance of $624.02. Now that the $750 deductible has been met, the enrollee is also responsible to pay the $200 copayment. The total amount the enrollee owes is: $824.02.

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time myocardial perfusion imaging Therefore, we decided that the Plan does not have to waive the deductible and copayment for myocardial perfusion imaging.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the echography provided on October 29, 2020.
You asked the Plan to waive the coinsurance for the echography. You say that this should be covered because you already paid the $15 copayment. You say you cannot see paying two copayments. The Plan denied your request. The Plan says the claim was reprocessed, and you have been asked to pay 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 20% coinsurance for up to a maximum of $75 per day for Medicare-covered diagnostic radiology services. You have been asked to pay $30.97 which is 20% of the allowed amount for the echography. The allowed amount is $154.86. ($154.86 x 20% = $30.97). The echography falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows the echography was performed during the office visit and is considered an additional service.
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 echography provided on October 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1833) and suspension sleeve (L2397) provided on October 29, 2020.
You asked the Plan to pay for a knee orthosis and suspension sleeve. You say that the requested items are medically necessary. The Plan denied your request. The Plan says rules for payment have not been met.
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 does not contain a valid proof of delivery for the supplies provided in this case. The document provided as proof of delivery indicates a need for an adult signature but is not signed. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1833) and suspension sleeve (L2397) provided on October 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram (EEG) services coded 95822 provided on July 1, 2020.
You asked the Plan to pay for the electroencephalogram (EEG) services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 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 code 95822 is electroencephalogram (EEG); recording in coma or sleep only. We find that CPT code 95822 is not supported in the medical record. Specifically, the billed place of service 15 (mobile unit) is not supported. The documentation shows that the enrollee was an inpatient at the time services were provided. Based on this information, we decided that Medicare rules for coverage of the electroencephalogram (EEG) services have not been met. Therefore, we decided that the Plan does not have to pay for the electroencephalogram (EEG) services coded 95822 provided on July 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical treatment of a hip fracture after a fall. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found the enrollee's condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Superion Interspinous spacer device provided on
November 6, 2020.
You asked the Plan to pay for the device. The Plan denied your request. The Plan says this is not medically
necessary.
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 pay for the device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that the Superion device is experimental. More research is needed to show safety and efficacy.
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 device have not been met. Therefore, we decided that the Plan does not have
to pay for the Superion Interspinous spacer device provided on November 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on
August 28, 2020.
You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says you must receive your care from a network provider. In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be covered. If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. You, or your PCP, must obtain authorization from the plan prior to seeking 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 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 a hospital outpatient clinic visit provided on August 28, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient therapy out of network.

You asked the Plan to pre-approve out of network providers. You say that you prefer to see the requested provider. The Plan denied your request. The Plan says this service can be provided in 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 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 outpatient therapy out of network.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the venous device blood draw provided on September 21, 2020.
You asked the Plan to waive the copayment for the venous device blood draw. You say that lab services have a $10 copayment according to your health plan. You say that the bill is not justified. The Plan denied your request. The Plan says the copayment 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 a $275 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay $110.73, which is less than the standard $275 copayment for the venous device blood draw. The venous device blood draw 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 copayment for the venous device blood draw provided on September 21, 2020.