Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Favorable

We decided that the Plan has to pre-approve Entyvio.

You asked the Plan to pre-approve Entyvio. You say that the requested Entyvio is medically necessary. The Plan denied your request. The Plan says that the enrollee must try and fail Infliximab first.

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 Entyvio. Our reviewer says that the requested Entyvio is medically necessary. Our physician reviewer found in this case, the enrollee was diagnosed with invasive intraductal breast cancer and treated with partial mastectomy and sentinel node biopsy followed by radiation and hormonal therapy. DrugDex, a Medicare approved compendium indicates that the plan's preferred alternative infliximab is associated with malignancies (lymphoma, leukemia, melanoma, nonmelanoma skin, breast, colorectal, cervical) with increased risk among women over the age of 60, patients with Crohn's disease, rheumatoid arthritis, or plaque psoriasis, particularly those with highly active disease and chronic immunosuppressant exposure. While some studies fail to show an increased risk of breast cancer recurrence when using TNF inhibitors, these studies generally do not include patients with recent diagnosis and treatment of the cancer. The prescriber has made a sufficient strong argument supported by literature that the plan's required alternative is not appropriate for the enrollee.

The elements of step therapy 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 Entyvio have been met. Therefore, we decided that the Plan has to pre-approve Entyvio.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited (problem-focused) evaluation (D0140), intraoral periapical x-ray (D0220), gingival irrigation (D4921), incision and drainage of abscess (D7510) and bone replacement graft (D7953) provided on December 15, 2020.
You asked the Plan to pay for the dental services. You say that the Plan told you this provider was in-network, so it is unfair for the Plan to deny this claim. The Plan denied your request. The Plan says they have agreed to provide a one-time exception and treat these services as in-network care. You will receive partial payment for the extraction, as it is a covered service. However, the problem-focused exam, intraoral periapical x-ray, gingival irrigation, incision and drainage of an abscess and bone replacement graft cannot be paid. These services are not covered by Medicare or by the Plan's supplemental dental benefit, regardless of the provider's network status.
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 a limited (problem-focused) evaluation (D0140), intraoral periapical x-ray (D0220), gingival irrigation (D4921), incision and drainage of abscess (D7510) and bone replacement graft (D7953) provided on December 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion/specialty drug administration services coded 99602 and 99601 provided on September 21, 2020.
You asked the Plan to pay for the home infusion/specialty drug administration 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 payable.
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 99602 and 99601 are not supported in the medical record. Specifically, these codes have a status code of "I". A status code of I means that these services are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion/specialty drug administration services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion/specialty drug administration services coded 99602 and 99601 provided on September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (97032, 97010) provided to you from October 21, 2020, to December 3, 2020.
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says these services are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services (97032, 97010) provided to you from October 21, 2020, to December 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital stays provided from October 6, 2020, to December 28, 2020.
You asked the Plan to waive the copayment for inpatient hospital stays. You say that you feel that the services received during your third surgery should have been performed during the first and second surgery and disagree with 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 $500 copayment per admission for inpatient hospital care. You received inpatient hospital care from October 6, 2020, to October 15, 2020. Therefore, you are responsible to pay the $500 copayment. You received inpatient hospital care from December 4, 2020 to December 28, 2020. Therefore, you are responsible to pay the $500 copayment. The total amount you owe is: $1,000. You have been asked to pay the total copayment amount of $1,000 for inpatient hospital stays. Inpatient hospital stays fall within the inpatient hospital care 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 inpatient hospital stays provided from October 6, 2020, to December 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular disease screening provided on November 23, 2020.
You asked the Plan to pay for the cardiovascular disease screening. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says Preventive and Screening Services do not include the billed CPT codes in their list of covered tests for cardiovascular screening.
The Plan follows Medicare rules. The rules explicitly say that a claim that is submitted for Cardiovascular Disease Screening shall be submitted with the CPT codes listed above. The test at issue in this appeal, the cardiovascular disease screening, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Specifically, this claim was not billed with the required CPT codes for cardiovascular disease screening. Additionally, the record does not include any medical records to determine if Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular disease screening provided on November 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on September 22, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 the physician services provided on September 22, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the chest.
You asked the Plan to pre-approve CT scan. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this test is correct, because there is no support for advanced imaging without biopsy.
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 CT scan. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested CT scan. Our physician reviewer found the records provided do not indicate the reasoning behind pursuing a CT scan of the chest in this enrollee to further evaluate a fluid filled collection in the left axilla. Given that the diagnoses under investigation are not mentioned and other avenues of evaluation such as biopsy of the fluid collection can be pursued, a CT scan is not medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the chest.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forMagnetic Resonance Imaging (MRI) of the cervical spine (72141).You asked the Plan to pay forthe MRI. You say that the MRI is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that MRIs 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 pay for the MRI. Our reviewer says that the MRI is not medically necessary. Our physician reviewer found a CT scan in March 2021 demonstrated mild spinal canal stenosis and foraminal narrowing.The enrollee has not tried and failed conservative therapy, including physical 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 MRI have not been met.Therefore, we decided that the Plan does not have to pay for Magnetic Resonance Imaging (MRI) of the cervical spine (72141)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on August 5, 2020.
You asked the Plan to pay for a pneumatic compression device. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on August 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on January 11, 2021.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you cannot afford the 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 $403 copayment per day, days 1-5, beginning with the day of admission. You have been asked to pay a $403 copayment for the inpatient hospital stay. The inpatient hospital stay falls within the "Inpatient hospital care" 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 inpatient hospital stay provided on January 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on October 11, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you told the ambulance service that the hospital was not in-network and had to be transported a second time and disagree with 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 $275 copayment for ambulance services. You have been asked to pay a $275 copayment for ambulance services. Ambulance services fall within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on October 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physician services rendered on October 26, 2020.
You asked the Plan to waive the copayment for these services. You say that you had an outpatient procedure with no office visit. The Plan denied your request. The Plan says the copayment 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 $15 copayment for each covered visit or consultation in an outpatient location with a specialist.
Review of the file shows that you received specialist services on October 26, 2020 prior to a procedure. These services were separate from the procedure. You have been asked to pay a $15 copayment for these services. These services fall within the covered visit or consultation in an outpatient location with a specialist 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 physician services rendered on October 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe podiatry office visit and ankle foot orthosis provided on November 17, 2020.You asked the Plan to waive the copayments forthe podiatry office visit and orthosis. You say that the provider told you the orthosis would not cost you anything.The Plan denied your request. The Plan says you were charged the copayments 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 $45 copayment for Physician service with a specialist,and20% coinsurancefor Durable Medical Equipment.You have been asked to pay a $45 copayment for the podiatry office visit and 20% coinsurance for the orthosis. This means that you have been asked to pay the correct amount based on your contract with the Plan. This costsharing 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 podiatry office visit and the ankle foot orthosis provided on November 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for negative pressure wound therapy electrical pump (E2402) provided November 7, 2020.
You asked the Plan to pay for negative pressure wound therapy pump. You say that please see all of the documentation requested. Please process this claim for payment. The Plan denied your request. The Plan says CMS does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient in hospital. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made between the facility and hospital and outside providers. The enrollee received the services in the facility during inpatient hospitalization. Payment for this service would be included in the Part A DRG payment to the facility. Payment for this service is the responsibility of the facility. Based on this information, we decided that Medicare rules for coverage of negative pressure wound therapy pump have not been met. Therefore, we decided that the Plan does not have to pay for negative pressure wound therapy electrical pump (E2402) provided November 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on December 2, 2020.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for nurse practitioner services provided on December 2, 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.
You asked the Plan to pre-approve IRF care. You say that the enrollee requires a coordinated team approach to care and is reasonably expected to benefit from IRF. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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. While the 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 the 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 acute inpatient rehabilitation facility (IRF) admission and services.