Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep sedation.

You asked the Plan to pre-approve deep sedation. You say that the services are necessary. The Plan denied your request. The Plan says the services are not a covered 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 deep sedation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466).

You asked the Plan to pre-approve a home ventilator. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested item is not medically necessary.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 home ventilator. Our reviewer says that the requested item is not medically necessary. Our physician reviewer found that the enrollee has chronic obstructive pulmonary disease (COPD) requiring supplemental oxygen. There is no documentation of carbon dioxide (CO2) retention with an arterial blood gases test (ABG) done while the enrollee is awake and stable. Even if the enrollee retains CO2, a bi-level positive airway pressure device (BiPAP) would be the appropriate treatment. Certain BiPAP devices can provide the non-invasive auto-titrating ventilation (AVAPS-AE) mode of ventilation that has been ordered. Medicare does not cover a ventilator when used as a BiPAP. 

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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda solution 100 mg/4 ml 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 medical studies haven't proven that this drug is helpful when you've already tried it.

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 not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee has squamous cell cancer of the tonsil, stage IV non-keratinizing poorly differentiated. The record indicates that the enrollee has had progression of disease with hepatic metastases after receiving the requested drug and radiation. The enrollee has refused chemotherapy. The Medicare approved cancer compendia do not provide support for the requested drug's use in this clinical scenario.

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 not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda solution 100 mg/4 ml for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visit to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the outpatient office visit. You say that you would like reconsideration because you used to see this provider and would like to see a doctor who is already aware of your condition and health history. The Plan denied your request. The Plan says there are network providers available who can provide the specialized care that you requested.

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 the outpatient office visit to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (43501) provided December 29, 2020.

You asked the Plan to pay for the surgical 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. 

In this case, the CPT Code Manual definition of code 43501 is Gastrotomy; with suture repair of bleeding ulcer. 

We find that CPT code 43501 is not supported in the medical record. Specifically, the operative report does not describe a suture repair being performed. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (43501) provided December 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance transportation services (A0428, A0427) provided on August 15, 2020, August 25, 2020, and September 5, 2020.

You asked the Plan to waive the copayments for the ambulance transportation services. You say that you should not be held liable for charges for services that were related to your COVID-19 diagnosis or services that were deemed medically necessary. The Plan denied your request. The Plan says the cost sharing was 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 $240 copayment for each Medicare-covered one-way trip via ground ambulance. 

You have been asked to pay a $240 copayment for each of the ambulance trips. You feel that you should not be responsible for the cost sharing amounts for these services, as they were medically necessary and related to COVID-19. The COVID-19 Emergency Declaration does include certain provisions and extra flexibility to certain healthcare coverage rules; however, none of these changes or provisions are related to the Plan's cost-sharing requirements for covered ambulance services. The Plan agreed that these services were medically necessary and has covered their share of the cost, however this does not mean you are exempt from your responsibility of cost sharing. Each of these ambulance services, both emergent and non-emergent, are considered Medicare-covered one-way trips via ground ambulance. 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 copayments for the ambulance transportation services (A0428, A0427) provided on August 15, 2020, August 25, 2020, and September 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo and Nivolumab 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 the use of this regimen requires no disease progression.

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 not medically reasonable or necessary. Our physician reviewer found the combination of Nivolumab and Ipilumumab are FDA-approved for first-line therapy. The enrollee has progressed on first-line maintenance therapy with Durvalumab. Continued immunotherapy would not be indicated.

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 not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo and Nivolumab for the enrollee.
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
services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and
effectively provide medically necessary and reasonable treatment in a SNF. The enrollee's functional level does
not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist
to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not
require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a
SNF. As a practical matter this enrollee does not require the necessary services on 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a new or replacement of a permanent pacemaker including upper and lower chamber electrodes.

You asked the Plan to pre-approve insertion of a new or replacement of a permanent pacemaker including upper and lower chamber electrodes. 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. 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 insertion of a new or replacement of a permanent pacemaker including upper and lower chamber electrodes. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records provided, the enrollee has neither documented evidence of symptomatic non-reversible sinus bradycardia on the June Holter monitor nor are there clearly documented symptoms that can be correlated with bradycardia in the clinical records that are provided. He would therefore not meet the medical necessity and reasonableness criteria of the applicable CMS Section 1862(a)1(A) rule. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of a new or replacement of a permanent pacemaker including upper and lower chamber electrodes have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of a new or replacement of a permanent pacemaker including upper and lower chamber electrodes.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (27329, 27364) provided November 12, 2020.

You asked the Plan to pay for the surgical 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. 

In this case, the CPT Code Manual definition of codes 27329 and 27364 are Radical resection of tumor (eg, sarcoma), soft tissue of thigh or knee area. 

We find that CPT code 27329 and 27364 is not supported in the medical record. Specifically, the operative report does not support that the billed services were performed. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (27329, 27364) provided November 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0425, A0429) received February 25, 2021.

You asked the Plan to waive the copayment for the ambulance transportation. You say that the Plan agreed that
claims should be processed as in-network for a specified amount of time. The Plan denied your request. The
Plan says the same copayment applies for Ambulance Services, regardless of the network status of the
provider.

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 a $290 copayment for Ambulance Services.

The enrollee has been asked to pay a $290 copayment for the ambulance transportation. The ambulance
transportation falls within the Ambulance Services 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 copayment for the ambulance transportation (A0425, A0429) received February 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider
on March 5, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
approved in advance.

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 had network providers
available who could have provided the services at issue in this appeal. 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 the services provided to you by an out-of-network
provider on March 5, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.

You asked the Plan to pre-approve Euflexxa. You say that you would like reconsideration because the Euflexxa is medically necessary. The Plan denied your request. The Plan says you do not meet step therapy exception criteria.

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 Euflexxa. Our reviewer says that the Plan requires a trial of Orthovisc, Synvisc or Synvisc-One before they will approve the requested drug. You have not tried and failed a trial of the Plan's preferred drugs. Our physician reviewer found the documentation does not show that the Plan's required drugs would likely be less effective or have adverse effects. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the echocardiogram provided on June 15, 2020.

You asked the Plan to reduce the copayment for the echocardiogram. You say that you should be charged a $110 copayment. The Plan denied your request. The Plan says 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 a $250 copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.

You have been asked to pay a $250 copayment for the echocardiogram. The echocardiogram falls within the "Outpatient Surgery and Other Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows the echocardiogram was provided by an outpatient hospital. 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 reduce the copayment for an echocardiogram provided on June 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth distant site service (G2025) rendered by the
out of network (OON) provider on January 8, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service 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 this service. Therefore, we decided that the Plan
does not have to pay for the telehealth distant site service (G2025) rendered by the out of network (OON)
provider on January 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on March 17, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 $40 for a Medicare-covered diagnostic hearing exam and an annual routine hearing test. Additionally, you pay $40 for each covered visit or consultation in an outpatient location with a specialist.

You have been asked to pay a $40 copayment for the specialist office visit 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 copayment for the office visit (99213) provided on March 17, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy (90832) rendered by the out of network (OON) provider on August 10, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the psychotherapy (90832) rendered by the out of network (OON) provider on
August 10, 2020.