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

We decided that the Plan does not have to pre-approve Oxaliplatin (J9263), Fluorouracil (J9190), Leucovorin
(J0640), and Nivolumab (J9299).
You asked the Plan to pre-approve Oxaliplatin, Fluorouracil, Leucovorin, Nivolumab. You say that these drugs
are medically necessary. The Plan denied your request. The Plan says this therapy cannot be recommended for
this enrollee.
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 Oxaliplatin, Fluorouracil, Leucovorin,
Nivolumab. Our reviewer says that the requested drugs are not medically reasonable and necessary for the
enrollee's condition. Our physician reviewer found the enrollee is a 66-year-old male with stage IV gastric
cancer. The requested drugs are not FDA-approved for the enrollee's cancer diagnosis. In addition, their use is
not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved
medical journal. A study has been published recommending these drugs based on a PD-L1 CPS score of 5 or
more and this patient is only at 2.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Oxaliplatin, Fluorouracil, Leucovorin, Nivolumab have not been met.
Therefore, we decided that the Plan does not have to pre-approve Oxaliplatin (J9263), Fluorouracil (J9190),
Leucovorin (J0640), and Nivolumab (J9299).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder Detect (0012M) provided on October 27, 2020.
You asked the Plan to pay for the CxBladder Detect. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says this service does not meet Medicare's criteria of medically reasonable and necessary and cannot be approved.
The Plan must follow Medicare rules. Medicare rules say that for the CxBladder assay coded as 0012M, non-coverage was reaffirmed by Medicare. We find that CPT code 0012M is not supported in the record. Specifically, this testing is not a Medicare covered benefit. Based on this information, we decided that Medicare rules for coverage of the CxBladder Detect have not been met. Therefore, we decided that the Plan does not have to pay for CxBladder Detect (0012M) provided on October 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided by a participating provider on October 20, 2020.
You asked the Plan to waive the copayment for urgently needed services. You say that you had to go to urgent care because you could not get into your dermatologist. You say that you think this is way too much. 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 $45 copayment for urgently needed services/in-network. You have been asked to pay a $45 copayment for urgently needed services. The correct copayment has been applied to the services that were provided. Urgently needed services falls within the urgently needed services/in-network 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 urgently needed services provided by a participating provider on October 20, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing for home INR testing materials. We decided that the Plan does not have to reduce the cost-sharing for home INR testing materials.
You asked the Plan to reduce the cost-sharing for home INR testing materials. You say that your cost-sharing should only be 20% coinsurance which results in a charge of $18.46 per month. The Plan says that the copayment amounts you are being charged are correct.
We decided that the Plan has to reduce the cost-sharing for home INR testing materials.
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 enrollees must pay 20% coinsurance for home INR testing materials. The allowed amounts of these claims total $979.25, resulting in a total coinsurance obligation of $195.85.
The Plan says you must pay $45 copayment for each billing of home INR testing materials. Based on the Plan contract, however, you cannot be asked to pay more than 20% coinsurance for home INR testing materials.
Therefore, we decided that the Plan has to reduce the cost-sharing for home INR testing materials from $450 total copayment amount to $195.85 total coinsurance amount.
We also decided that the Plan does not have to reduce the cost-sharing for home INR testing materials to the full extent that you requested.
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 home INR testing materials. You requested that the Plan reduce your cost-sharing to $18.46 per claim, which would result in a total coinsurance amount of $184.60. However, the allowed amounts of the claims total $979.25, resulting in a total coinsurance obligation of $195.85. Therefore, we decided that the Plan does not have to reduce the cost-sharing for home INR testing materials to the full extent that you requested.
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 an eye exam (92014, 92015) provided on October 29, 2020.
You asked the Plan to pay for the eye exam. The Plan denied your request. The Plan says supplemental vision
services will only be covered when they are received from an in-network provider. You used an out-of-network
provider for these services.
Medicare generally does not cover routine vision and eyewear services. 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 these services when they are received from an in-network provider.
We looked at the file and the Plan's rules. You used an out-of-network provider for these services. Based on
this information, we decided that the Plan's rules for coverage of the eye exam have not been met. Therefore,
we decided that the Plan does not have to pay for an eye exam (92014, 92015) provided on October 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre sensors.
You asked the Plan to pre-approve Freestyle Libre sensors. You say that these are medically necessary for you. The Plan denied your request. The Plan says that you do not meet criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of Freestyle Libre sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre sensors.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on October 22, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you needed a tooth extracted and were unable to receive the extraction without the exam. The Plan denied your request. The Plan says you had exceeded the frequency limitation under your dental plan.
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, oral examinations are limited to two per calendar year. The record shows that you received oral exams on June 4, 2020, and June 26, 2020, and your oral exams benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on October 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on December
23, 2020.
You asked the Plan to pay for the dental service. You say that you were diagnosed with periodontal disease a
few years ago. You also say that periodontal maintenance is necessary at least 2 times per year for your
continued good health. The Plan denied your request. The Plan says periodontal maintenance is not listed as a
covered service. The Plan also says that you did not contact the Plan to verify benefits or provider eligibility
prior to receiving the service.
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 the
periodontal maintenance (D4910) provided on December 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultra-lightweight manual wheelchair for the enrollee.
You asked the Plan to pre-approve an ultra-lightweight manual wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no information that the enrollee is a full-time wheelchair user or needs special adjustments, a specialty evaluation, assistive technology professional involvement or a signed order.
The Plan must follow Medicare rules. Medicare rules say that a manual wheelchair can be covered if the beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided. We looked at the file and Medicare rules. The file does not include a home evaluation to confirm a manual wheelchair can be used in the home. Based on this information, we decided that Medicare rules for coverage of an ultra-lightweight manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultra-lightweight manual wheelchair for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder test provided on October 13, 2020.
You asked the Plan to pay for the testing services. You say that the testing is eligible for payment as long as the service meets the medical necessity guidelines. The Plan denied your request. The Plan says the test does not meet Medicare's criteria.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. In this case, there are insufficient records to show that the ordered testing is diagnostic, prognostic, or clearly correlates any test result with given interventions. 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 pay for the CxBladder test provided on October 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre 14 day sensors for the enrollee.
You asked the Plan to pre-approve Freestyle Libre 14 day sensors. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet Medicare criteria for these services.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of Freestyle Libre 14 day sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 14 day sensors for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (CPT 27095) provided to the enrollee on September 16, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this denial is for not meeting the Medically Unlikely Edits (MUE) for CPT 27095.
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 27095 is "Injection procedure for hip arthrography." 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 CPT 27095 has an MUE (Medically Unlikely Edit) status of 2 , which means billing this code twice on the same date of service in not appropriate, therefore 27095 50 and 27095 50 is not eligible for reimbursement. 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 surgical services (CPT 27095) provided to the enrollee on September 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incomplete endodontic therapy (D3332) received December 23, 2020.
You asked the Plan to pay for the incomplete endodontic therapy. You say that you have over $600 of your benefit left for 2020. The Plan denied your request. The Plan says the service provided is not a covered benefit under your dental plan.
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 the incomplete endodontic therapy (D3332) received December 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam (92014) provided on September 22, 2020.
You asked the Plan to waive the copayment for the eye exam. You say that this was a routine eye exam and should be covered with no copay. The Plan denied your request. The Plan says this eye exam was billed with a medical diagnosis code, which means that this is a diagnostic exam rather than a routine exam. Medical records were provided to support this assessment. There is a $30 copayment required for Medicare-covered exams to diagnose and treat conditions of the eye.
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 $30 copayment for Medicare-covered exams to diagnose and treat diseases and conditions of the eye. You have been asked to pay a $30 copayment for the eye exam. The eye exam was billed with a medical diagnosis other than a refractive diagnosis (such as nearsightedness or farsightedness). Exams that are billed with medical diagnoses are generally considered diagnostic, whereas routine services are provided when there is no evident cause for concern. This eye exam is therefore considered a Medicare-covered exam to diagnose and treat diseases and conditions of the eye. 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 eye exam (92014) provided on September 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on November 2, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan must follow Medicare rules. The rules say that the CxBladder testing is non-covered. We looked at the file and Medicare rules. The test at issue is CxBladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on November 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that you are suitable for transfer to the
LTACH and cannot be adequately cared for in your current condition at a skilled nursing facility. The Plan
denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 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 health care setting being offered by the Plan. The
requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and
condition 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
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 the enrollee requires 42 days of IV antibiotics and daily hyperbaric treatment. The Plan denied your request. The Plan says the enrollee does not have complicated wounds or medications that cannot be given in the current location.
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 physician reviewer found that the enrollee was admitted to the acute hospital for cellulitis of the right toe with abscess and osteomyelitis. The enrollee is receiving appropriate care at the present acute care hospital. He does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that he requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not 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 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal paracentesis provided on October 14, 2020.
You asked the Plan to pay for the surgical service. You say that the services should be covered. The Plan denied your request. The Plan says the enrollee was receiving hospice care on the date of service in this case. The Plan says that services that the enrollee received while enrolled in hospice are not payable under the Plan. The Plan also says that the provider should submit claims to the Original Medicare.
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 enrollee was 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 abdominal paracentesis provided on October 14, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care and closed treatment of shoulder dislocation provided on August 27, 2020.
You asked the Plan to pay for closed treatment of shoulder dislocation, with manipulation; without anesthesia (23650). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not include a procedure note detailing that closed treatment of shoulder dislocation, with manipulation; without anesthesia was 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. We find that closed treatment of shoulder dislocation, with manipulation; without anesthesia is not supported in the medical record. Specifically, there are no details of this procedure being performed. Based on this information, we decided that Medicare rules for coverage of closed treatment of shoulder dislocation, with manipulation; without anesthesia (23650) have not been met. Therefore, we decided that the Plan does not have to pay for critical care and closed treatment of shoulder dislocation provided on August 27, 2020.