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

We decided that the Plan does not have to pre-approve dental services (D2950, D4910, D4921).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is 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
dental services (D2950, D4910, D4921).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit (99284) provided on March 24, 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 a $120 copayment per visit for Medicare-covered emergency room visits. 

You have been asked to pay a $120 copayment for the emergency room 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 emergency room visit (99284) provided on March 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically necessary, and your current hospital does not have the specialty services you require. The current facility does not have a pulmonologist on staff and you require a tracheostomy. The Plan denied your request. The Plan says you are currently receiving the appropriate care, and a transfer to an LTACH would not provide a clinical advantage. The Plan will continue to cover medically necessary acute and critical care at the current facility until your condition is stable for transfer to a lower level of care, or until the clinical circumstances change such that an LTACH may be reconsidered.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation provided necessitating admission to a LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services
available at the LTACH that you require that are not available at the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography, thorax, low dose for lung cancer screening, without contrast material (71271).
You asked the Plan to pre-approve the low dose CT scan. You say that you would like to appeal the denial of the low dose CT for lung cancer screening. The Plan denied your request. The Plan says the enrollee does not meet the criteria for a screening Lung CT scan and a non-screening diagnostic CT scan of the chest would be approved.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above-described criteria.
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 low dose CT scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has previously had a CT scan that demonstrated lung nodules. The requested CT scan is to follow up on that finding. The case file indicates that the plan will approve a standard thoracic CT scan. The elements of the coverage criteria for the requested service are not satisfied. 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 low dose CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography, thorax, low dose for lung cancer screening, without contrast material (71271).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on July 8, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the testing services. You say that you are requesting full payment. The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain 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. The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the lab 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 Guardant360 testing provided on July 8, 2020 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (73560) provided December 30, 2020.

You asked the Plan to pay for the x-ray. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not billed with a required modifier.

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 code 73560 is not supported in the medical record. Specifically, the beneficiary was a Part A SNF inpatient when the service was rendered. The code must be billed with modifier 26. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (73560) provided December 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the oncology gene expression profiling provided on December 22, 2020.

You asked the Plan to pre-approve the oncology gene expression profiling. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided were 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 pre-approve the oncology gene expression profiling. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found urinary biomarkers are insufficiently accurate to replace cystoscopy for diagnosis/surveillance, though some appear to have predictive ability for assessing response to intravescial Bacillus Calmette-Gurin (BCG) and may help interpret indeterminate cytology. "At the time of first disease evaluation and treatment, none of the existent risk stratification tools or urinary biomarkers are sufficiently sensitive and specific to predict which patient will have an early tumor recurrence. Therefore, the most reliable way to know whether enrollees are at risk for early recurrence is by cystoscopic evaluation." These tests are considered investigational and/or experimental. The documentation does not support that the enrollee had a diagnosis/condition that would meet criteria for the services rendered. 

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 oncology gene expression profiling have not been met. Therefore, we decided that the Plan does not have to pre-approve the oncology gene expression profiling provided on December 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic shoe inserts (A5500, A5514, A9900) provided
January 24, 2020.

You asked the Plan to pay for the diabetic shoe inserts. You say that the items were medically necessary. The
Plan denied your request. The Plan says insufficient clinical documentation was provided to support the claim.

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 relevant medical records which support medical necessity for the supplies provided in this case. 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 diabetic shoe inserts (A5500, A5514, A9900) provided January 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (S9338) provided on October 21, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Code S9338 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (S9338) provided on October 21, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of home health physical therapy services.

You asked the Plan to pre-approve the continuation of home health physical therapy services. You say that home health care continues to be medically necessary. The Plan denied your request. The Plan says home health care is no longer medically reasonable and necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the continuation of home health physical therapy services. Our reviewer says that the requested home health services are no longer medically necessary and reasonable. Our physician reviewer found that the enrollee appears to have progressed to a level where he is no longer homebound, can do a home exercise program, and can attend outpatient therapy. As such, ongoing home health physical therapy services are not medically necessary or reasonable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the continuation of home health physical therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of home health physical therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a progressive lens (V2781) and standard frames (V2020) provided on March 8, 2021.

You asked the Plan to pay for a progressive lens and standard frames. You say that you have type 2 diabetes and get glasses every year. The Plan denied your request. The Plan says you received the progressive lenses and standard frames on July 15, 2020.

The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one standard lens and frame once every 2 years. The Plan contract says for people with diabetes, screening for diabetic retinopathy is covered once per year. 

The services you asked the Plan to pay for are considered routine vision services or eyewear. The record shows that the Plan covered a progressive lens and standard frame for you on July 15, 2020. This means that you have exhausted the Plan's benefit for standard lenses and frame and were not eligible for another pair on March 8, 2021. Therefore, we decided that the Plan does not have to pay for a progressive lens (V2781) and standard frames (V2020) provided on March 8, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve use of Zarxio (filgrastim).

You asked the Plan to pre-approve Zarxio. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because Zarxio is not medically necessary.

The Plan follows Medicare rules. Medicare rules state that G-CSF filgrastim may be used for FDA approved indications or certain additional indications. 

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 Zarxio. Our reviewer says that the enrollee meets the Medicare criteria for the requested use of Zarxio. Our physician reviewer found Zarxio is Food & Drug Administration approved to decrease the incidence of infection (neutropenic fever) in patients with nonmyeloid malignancies receiving myelosuppressive chemotherapy associated with a significant incidence of severe neutropenia with fever. The enrollee on immunosuppressive chemotherapy is older than age 65, has an indwelling drain, and is noted to have neutropenia after chemotherapy which in combination makes him high risk for neutropenic fever.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zarxio have been met. Therefore, we decided that the Plan has to pre-approve use of Zarxio (filgrastim).

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 waive the copay for the inpatient hospital services provided from February 4, 2021, to February 5, 2021.

You asked the Plan to waive the copay for the services provided. You say that you were charged for an overnight stay. The Plan denied your request. The Plan says the cost was based on your in-network benefits.

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 $300 copay per day for days 1-5 for inpatient hospital care. 

You have been asked to pay a $300 copay for the services provided. The services 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 copay for the inpatient hospital services provided from February 4, 2021, to February 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye refraction for eyeglasses and contacts (92015) provided on March 19, 2021.
You asked the Plan to waive the copayment for an eye refraction. You say that you had a routine eye visit and should not be charged. The Plan denied your request. The Plan says you had a routine eye exam. The Plan also says that you received an eye refraction for eyeglasses and contacts which is not part of the routine eye exam.
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 $10 copayment for additional services such as eye refractions, for vision care.
You have been asked to pay a $10 copayment for an eye refraction. The records show you were seen by the provider for a routine eye exam. The records also show you received services for an eye refraction for eyeglasses and contacts, however, an eye refraction is not part of the routine eye exam. The EOC confirms $10 is the required copayment for this service. An eye refraction falls within the vision 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 an eye refraction for eyeglasses and contacts (92015) provided on March 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the OON CT scan. You say that the clinical information provided supports the need for the requested CT scan. The Plan denied your request. The Plan says the requested service can only be allowed when done by a provider that is within the limited plan network. The Plan says that the requested provider is not contracted with the Plan.
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 computed tomography (CT) services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal surgery.

You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870). You say that this treatment is considered safe and effective and the enrollee is not a good candidate for an invasive surgical procedure. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational.

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 interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the interspinous process devices are experimental at this time. More research is needed to show safety and efficacy of the devices. 

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 interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870) have not been met. Therefore, we decided that the Plan does not have to pre-approve the spinal surgery.