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

We decided that the Plan has to pre-approve Irinotecan Hydrochloride (J9206).

You asked the Plan to pre-approve Irinotecan Hydrochloride. You say that Irinotecan Hydrochloride is medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Irinotecan Hydrochloride. Our reviewer says that Irinotecan Hydrochloride is medically necessary. Our physician reviewer found the patient cannot get an infusion pump due to a history of injecting narcotics into it and alternative treatment is needed. Irinotecan Hydrochloride is appropriate as part of the chemotherapy regimen.

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 Hydrochloride have been met. Therefore, we decided that the Plan has to pre-approve Irinotecan Hydrochloride (J9206).

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: ER
Decision: Unfavorable

We decided that the Plan does not have to reimburse for medical care provided while traveling outside of the US.

You asked the Plan to reimburse for the medical care. You say that you say that you received a check for the amount of $1,503.85, and you did your own calculations and should have received $1,767.49. The Plan denied your request. The Plan says the check that you received was for $1503.85 US dollars, based on the foreign currency exchange rate for the services rendered outside of the US. The Plan states this amount excluded from the request was the expense paid for outpatient pharmacy costs, $263.64 US dollars for prescription drugs purchased at retail pharmacy outside of the US. The Plan states outpatient prescription drugs filled outside of the US on the service dates noted total $292.89 are not covered. The Plan states these out-of-pocket expenses are excluded from coverage as per your 2020 EOC page 118, which clearly states, "our plan cannot cover a drug purchased outside the United States and its territories."

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).

Upon review, it was determined the amount reimbursed in the amount of $1,503.85 for emergency world-wide medical services was found to be appropriate based on the plan's 2020 EOC. The health plan contract says that the plan cannot cover a drug purchased outside the United States and its territories. Therefore, we decided that the Plan does not have to reimburse for medical care provided while traveling outside of the US.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic imaging provided on November 20, 2020 by an out of network (OON) provider.

You asked the Plan to pay for diagnostic imaging. You say that you have never had to do this before. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that there are in-network providers available for these services.

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. T

he requested 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 diagnostic imaging provided on November 20, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a nuclear stress test provided by a participating provider on October 20, 2020.

You asked the Plan to waive the copayment for a nuclear stress test. You say that the stress test was not completed, and you should not be responsible for this copayment. The Plan denied your request. The Plan says the correct copayment 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 $200 copayment for outpatient diagnostic tests/nuclear scans. 

You have been asked to pay a $200 copayment for a nuclear stress test. This procedure had not modifiers attached to show the test was not completed; therefore, the correct copayment has been applied. A nuclear stress test falls within the outpatient diagnostic tests/nuclear scans 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 a nuclear stress test provided by a participating provider on October 20, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99284).

You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration because this claim was billed with the appropriate diagnosis code. The Plan denied your request. The Plan says this claim was not submitted with an appropriate diagnosis.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that CPT code 99284 is not supported in the record. Specifically, this claim was billed with diagnosis code H10.211. Per the ICD-10-CM, this diagnosis code has a code first note meaning that the underlying condition must be sequenced first. Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99284).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a non-participating provider on August 3, 2020, to August 13, 2020.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that this stay was involuntary. You say that you should not have to pay for this. The Plan denied your request. The Plan says the correct copayment 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 $440 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care/non-preferred. 

You have been asked to pay a $440 copayment per day for days 1-5. There is a $0 copayment for additional days for an inpatient hospital stay. You have been asked to pay $2,140.50, which is less than your copayment total of $2,200 ($440 x 5 days = $2,200). Since an inpatient hospital stay was provided, the correct copayment has been applied. An inpatient hospital stay falls within the inpatient hospital care/non-preferred 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 inpatient hospital stay provided by a non-participating provider on August 3, 2020, to August 13, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on September 24, 2020.

You asked the Plan to pay for the services provided. You say that the services should be covered by the plan. The Plan denied your request. The Plan says you were in hospice at the time of service.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The records show that you were under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the lab services provided on September 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing.

You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease.

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 services billed on this claim. Without this information, it cannot be determined whether this testing was performed for covered purposes. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical laparascopy with total hysterectomy for the enrollee.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says there has been no conservative management.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation in the case file is limited and does not support that a surgical laparascopy with total hysterectomy is medically reasonable and necessary for the enrollee in this case. There is no documentation of functional impairment or a lack of response to medical therapy. 

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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a surgical laparascopy with total hysterectomy for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided to the enrollee and billed under codes 99601 and 99602.

You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) codes 99601 and 99602 denied as invalid procedure codes for the services billed. The Plan says that the Medicare guidelines state codes 99601 and 99602 have a status code of "I". This indicates the code is not covered by Medicare. The Plan states a corrected claim would be accepted if submitted.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the codes submitted have a status indicator preventing payment for Medicare claims. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for services provided to the enrollee and billed under codes 99601 and 99602.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation trips exceed the benefit limit. Therefore, coverage criteria have not been met.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way transportation trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing / panels (CPT code (s): 81286, 81407, 81408, and 81479) provided to the enrollee.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Review of the file shows the enrollee has a diagnosis: Z82.49 - Family history of ischemic heart disease, VI42.8 - Other cardiomyopathies, and I42.2 - Other hypertrophic cardiomyopathy. Medicare denies coverage for all cardiovascular risk assessment testing / panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing / panels (CPT code (s): 81286, 81407, 81408, and 81479) provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits provided from August 26, 2020, to December 16, 2020.

You asked the Plan to waive the copayments for specialist visits. You say that you received services from a nurse practitioner, not a doctor, and feel that the copayments should be waived. 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 $20 copayment for specialist visits. 

You received specialist visits from August 26, 2020, to December 16, 2020, for a total of 6 visits. Therefore, you are responsible to pay a $20 copayment per each visit. The total amount you owe is: $20 (copayment) x 6 (visits) = $120. 

You have been asked to pay the total copayment amount of $120 for specialist visits. Specialist visits fall 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 copayments for specialist visits provided from August 26, 2020, to December 16, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan.

You asked the Plan to pre-approve Hyalgan. 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.

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 Hyalgan. Our reviewer says that the
medication is not medically necessary. Our physician reviewer found in this case, the enrollee has not tried and
failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s)
would likely be less effective and/or likely have adverse effects 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a revision of reconstructed breast procedure (19380).

You asked the Plan to pre-approve a revision of reconstructed breast procedure. You say that you need the requested service to complete physical therapy for your arm. The Plan denied your request. The Plan says rules for coverage have not been met because the requested service is related to follow-up care of a prior non-covered cosmetic surgery service.

The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. 

We looked at the file and Medicare rules. The requested service is a cosmetic procedure and related to a prior non-covered cosmetic procedure. Based on this information, we decided that Medicare rules for coverage of a revision of reconstructed breast procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a revision of reconstructed breast procedure (19380).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral/facial photographic image, panoramic x-ray, and adjunctive pre-diagnostic test.

You asked the Plan to pay for the 2D oral/facial photographic image, panoramic x-ray, and adjunctive pre-diagnostic test. You say that according to the Plan's provider directory, this provider is in-network. You also say that you believe these services should be covered. The Plan denied your request. The Plan says the 2D oral/facial photographic image and adjunctive pre-diagnostic test are not covered. The Plan also says that your benefits for the panoramic x-ray have been satisfied and the frequency limitation has been exceeded.

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 2D oral/facial photographic image and adjunctive pre-diagnostic test are not among those covered under this benefit. The contract says that full mouth or panoramic x-rays are limited to one procedure every three years. The record shows that you received a complete series of intraoral x-rays which was covered by the Plan, and your full mouth or panoramic x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 2D oral/facial photographic image, panoramic x-ray, and adjunctive pre-diagnostic test.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve intensity-modulated radiation therapy (IMRT).

You asked the Plan to pre-approve IMRT. You say that the services are necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 IMRT. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found given the guidelines endorsement of hippocampal sparing IMRT in the setting of prophylactic brain radiation, and at least on randomized trial demonstrating a benefit, the treatment is medically reasonable and necessary as it would be offered in accordance with accepted standards of 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 IMRT have been met. Therefore, we decided that the Plan has to pre-approve intensity-modulated radiation therapy (IMRT).

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiofrequency ablation (RFA) procedure.

You asked the Plan to pre-approve a RFA procedure. 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 follows Medicare rules. Medicare rules say that Thermal Medial Branch Radiofrequency Neurotomy is covered when specific criteria are met. 

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 RFA procedure. Our reviewer says that the services are not medically necessary. Our physician reviewer found the degree and duration of pain relief do not meet the coverage criteria. The procedure is considered not medically reasonable or 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 a RFA procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a radiofrequency ablation (RFA) procedure.