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

We decided that the Plan does not have to pre-approve Prochlorperazine maleate for the enrollee. You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under the enrollee's medical benefit. The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prochlorperazine maleate for the enrollee. Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for continued admission to an inpatient hospital for the enrollee.You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary.The Plan denied your request. The Plan says that the enrollee has met all of their goals.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. She has been evaluated and treated by internal Medicine, Infectious Disease, General Surgery, Gyn, Gastroenterology, Pulmonary, Nephrology, Psychiatry, Palliative care, and Pain Management. She continues to require and receive inpatient level of care hospital services. She is bedbound due to her MS 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 acute inpatient hospital care have been met.Therefore, we decided that the Planhas to pay forcontinued admission to an inpatient hospital for the enrollee.If the Plandoes not agree with our decision,they can ask us to open a case again. We only open a caseagain if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/orsend 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 core build up including pins (D2950) and pulp cap (D3110) provided April 8, 2019. 
 
You asked the Plan to pay for the dental services. You say that you have been going to this provider for years and you are appealing this decision. The Plan denied your request. The Plan says these services are not covered under the plan benefits. 
 
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. Services not listed under the Description of Benefit is not covered. 
 
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 core build up including pins (D2950) and pulp cap (D3110) provided April 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal decompression.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are part of a clinical trial.
The Plan must follow Medicare rules. The rules state that Medicare pays for the routine costs of qualifying clinical trials We looked at the file and Medicare rules. The file shows that the requested procedure is to be done as part of a clinical trial. Approval for these services must be submitted to Original Medicare. Therefore, we decided that the Plan does not have to pre-approve spinal decompression.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory tests provided on February 4, 2020.
You asked the Plan to waive the copayment for the laboratory tests. You say that yearly bloodwork should be no cost to you. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $10 per day, per in-network provider, for Medicare-covered lab services. You have been asked to pay a $10 copayment for the laboratory tests. The laboratory tests fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that you are only responsible for the $10 copayment. 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 laboratory tests provided on February 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vectibix.
You asked the Plan to pre-approve these services. You say that the enrollee is anxious to start chemotherapy.
The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has colon cancer diagnosed
in 2017. She has received prior treatment with Vectibix with progression. Treatment after progression is not the
standard of care, as most patients are refractory to subsequent use. Vectibix is therefore not reasonable or
medically 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Vectibix.
Appeal type: Inpatient Hospital
Decision: Unfavorable


 We decided that the Plan does not have to pay for the interpretation of the pre-operative chest x-ray provided on December 5, 2019. 
 
You asked the Plan to pay for the chest x-ray interpretation. You say that this is a correctly coded claim and should be paid. The Plan denied your request. The Plan says the use of diagnosis code Z01.818 requires an additional diagnosis code according to the ICD-10 Coding Guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that payment can only be made for services that are reasonable and necessary to diagnose/treat an illness/injury. Services provided without relation to a medical condition are not covered nor are services required by a third party. 
 
In this case, the chest x-ray was provided as a routine preoperative exam. There was no illness or injury reported in the diagnosis code section nor in the medical record for which this exam was deemed necessary. Routine preoperative x-rays may be required by certain providers but do not meet the Medicare definition of medically reasonable and necessary. Therefore, we decided that the Plan does not have to pay for the interpretation of the pre-operative chest x-ray provided on December 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Mohs micrographic technique provided on
February 24, 2020.
You asked the Plan to waive the copayment for Mohs micrographic technique. You say that you were told that
the insurance would fully cover the procedure. 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 $325
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
You have been asked to pay the allowed amount of $276.51, which is less than the $325 copayment for Mohs
micrographic technique. Mohs micrographic technique falls within the outpatient surgery, including services
provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the copayment for Mohs micrographic technique provided on February 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography angiography (CTA) of the abdomen. 
 
You asked the Plan to pre-approve the CTA of the abdomen. You say that the records provided support the need for the requested CTA. The Plan denied your request. The Plan says a CTA is not supported for the enrollee's problem because it would not show the doctor all of the details needed in order to treat her. 
 
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 the CTA of the abdomen. Our reviewer says that the requested CTA is not medically reasonable and necessary. Our physician reviewer found the enrollee has renal cell cancer being considered for robotic partial nephrectomy. In this circumstance the records do support the need for an abdominal CT with and without contrast but do not support the need for angiography. Moreover, a CT angiogram of the abdomen was performed already on July 18, 2018 showing calcification but no reports of aneurysm or dissection at that 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 the CTA of the abdomen have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography angiography (CTA) of the abdomen.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the walking boot provided on March 8, 2020. You asked the Plan to waive the coinsurance for the walking boot. You say that you were told you would not be charged for the walking boot. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for durable medical equipment, oxygen/oxygen equipment and related supplies. You have been asked to pay $41.03 which is 20% of the allowed amount for the walking boot. The allowed amount is $205.17. ($205.17 x 20% = $41.03). The walking boot falls within the "Durable medical equipment (DME) and related supplies" 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 coinsurance for the walking boot provided on March 8, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Meals on Wheels.
You asked the Plan to pre-approve the requested services. You say that the service should be covered because
you saw it on TV. The Plan denied your request. The Plan says the services are not a covered benefit.
Medicare does not cover home-delivered meals. The Plan follows the same rule.
We looked at the file and Medicare rules. The requested service is not covered by Medicare. Your plan does
not offer a supplemental benefit for these services. Based on this information, we decided that Medicare rules
for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve Meals on
Wheels.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95886) provided on December 6, 2018. You asked the Plan to pay for needle electromyography. You say that this code can be verified in the records. The Plan denied your request. The Plan says there is a more appropriate code for the service performed. 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 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure). 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 needle electromyography. Our reviewer says that this code is not supported. Our physician reviewer found the medical records submitted does not include documentation to validate that a needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels was performed on December 6, 2018, therefore this service cannot be verified. The procedure that was performed on December 6, 2018 requires a more appropriate code. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of needle electromyography have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95886) provided on December 6, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.
You asked the Plan to pre-approve Keytruda. You say that this is medically necessary for the enrollee. The
Plan denied your request. The Plan says that this regimen is not supported by compendia and cannot be
approved.
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 Keytruda. Our reviewer says that
Keytruda is not medically reasonable and necessary for the enrollee in this case. Keytruda is not FDA approved
in combination with carboplatin, pemetrexed and bevacizumab. The use is not supported by one of the major
drug compendia or by clinical research that appears in a CMS-approved medical journals. Our physician
reviewer found that the enrollee's condition does not meet Medicare criteria for Keytruda.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided by a participating provider on January 9, 2020.
You asked the Plan to waive the copayment for physical therapy. You say that you do not feel like the services that were performed were considered physical therapy. You say that you were not made aware that there would be an additional charge. 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 $15 copayment for outpatient rehabilitation services. You have been asked to pay a $15 copayment for physical therapy. The correct copayment has been applied to the services that were provided. Physical therapy falls within the outpatient rehabilitation 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 physical therapy provided by participating provider on January 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided to the enrollee from August 29,
2019 to August 30, 2019.
You asked the Plan to pay for the services. You say that the service was billed with modifier -59 and should be
reprocessed for payment. The Plan denied your request. The Plan says the services were not coded correctly.
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 the denied codes is:
CPT 88305:
Surgical pathology, gross and microscopic examination
CPT 88341:
Immunohistochemistry or immunocytochemistry, initial single antibody stain procedure
CPT 88342:
Immunohistochemistry or immunocytochemistry, each additional antibody stain procedure
We asked our coding 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 services. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our coding reviewer found the
documentation submitted was reviewed, and the documentation does not support the denied additional units
billed.
We looked at this coder's review, the file, and Medicare rules. 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 pathology services provided to the enrollee from August 29, 2019 to August 30, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.  
 
You asked the Plan to pre-approve Prolia. You say that the enrollee would like an exception to the step therapy rules. The Plan denied your request. The Plan says the enrollee has not tried and failed Zoledronic acid. 
 
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. The Plan requires trial and failure of Zoledronic acid prior to allowing coverage for Prolia. The medical records do not show the enrollee has tried and failed or had contradiction to Zoledronic acid.  Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the specialist office visits and the urine drug test provided on January 6, 2020 and January 15, 2020.
You asked the Plan to waive the cost share for the specialist office visits and the urine drug test. You say that you saw the nurse practitioner and should not be charged the specialist copayment. You also say you did not receive additional services on January 6, 2020. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $150 deductible that applies towards the urine drug test and a $35 copayment per specialist office visit. The urine drug test you asked the Plan to waive the cost share for falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 deductible that applies towards the urine drug test. The allowed amount for the urine drug test is $6.45. Therefore, $6.45 is the amount that is applied to your deductible. This cost sharing is a contractual obligation that had not been met at the time the urine drug test was received on January 6, 2020 to January 15, 2020. You have also been asked to pay a $35 copayment for each of the specialist office visits. The specialist office visits fall within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The medical record shows you were seen by the nurse practitioner, who is overseen by the radiologist, which is considered a specialist. The medical record also shows that a urine sample was collected on January 6, 2020.
Therefore, we decided that the Plan does not have to waive the cost share for the specialist office visits and the urine drug test provided on January 6, 2020 and January 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an attendant control.
You asked the Plan to pre-approve an attendant control. The Plan denied your request. The Plan says an
attendant control cannot be covered in addition to a beneficiary-operated joystick.
The Plan must follow Medicare rules. Medicare rules say that if an attendant control is provided in addition to a
beneficiary-operated drive control system, it will be denied as non-covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of an attendant control have not been met. Therefore, we decided that the Plan does not have to preapprove
an attendant control.